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Decision: unknown

 
The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. 
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
All of the following basic criteria (A-C) must be met for a power mobility device or a push-rim activated power 
assist device (E0986) to be covered. Additional coverage criteria for specific devices are listed below. 
A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, 
grooming, and bathing in customary locations in the home. A mobility limitation is one that: 
- Prevents the beneficiary from accomplishing an MRADL entirely, or 
- Places the beneficiary at reasonably determined heightened risk of morbidity or mortality 
secondary to the attempts to perform an MRADL; or 
- Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
B. The beneficiarys mobility limitation cannot be sufficiently and safely resolved by the use of an 
appropriately fitted cane or walker. 
C. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-
configured manual wheelchair in the home to perform MRADLs during a typical day. 
- Limitations of strength, endurance, range of motion, or coordination, presence of pain, or 
deformity or absence of one or both upper extremities are relevant to the assessment of upper 
extremity function. 
- An optimally-configured manual wheelchair is one with an appropriate wheelbase, device 
weight, seating options, and other appropriate nonpowered accessories. 
 
A push-rim activated power assist device (E0986) for a manual wheelchair is covered if all of the following 
criteria are met: 
1. All of the criteria for a power mobility device listed in the Basic Coverage Criteria section (see 
above) are met; and 2. The beneficiary has been self-propelling in a manual wheelchair for at least one year; and 
3. The beneficiary has had a specialty evaluation that was performed by a licensed/certified medical 
professional, such as a physical therapy or occupational therapist (PT or OT), or practitioner who 
has specific training and experience in rehabilitation wheelchair evaluations and that documents the 
need for the device in the beneficiarys home. The PT, OT, or practitioner may have no financial 
relationship with the supplier; and 
4. The wheelchair is provided by a supplier that employs a RESNA-certified Assistive Technology 
Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the 
wheelchair selection for the beneficiary. 
 
If all of the coverage criteria are not met, it will be denied as not reasonable and necessary. You can find these 
rules in Local Coverage Determination (LCD) Power Mobility Devices (L33789). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.