Appeal type: unknown
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 code E1226 describes a manually operated reclining back that reclines 80 degrees or greater. 
You can find this rule in the Local Coverage Article (LCA) - Wheelchair Options/Accessories - Policy Article 
(A52504) - Effective January 1, 2020. 
 
The rules say that a manual fully reclining back option (E1226) is covered if the beneficiary has one or more of 
the following conditions: 
1. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional 
weight shift; or 
 
2. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently 
transfer from the wheelchair to the bed. 
 
You can find this rule in the Local Coverage Determination (LCD) - Wheelchair Options/Accessories (L33792) 
- Effective January 1, 2020. 
 
The rules say that accessories provided with the initial issue of a transport chair are not separately billable with 
the exception of elevating legrests (E0990, K0195). You can find this rule in the Local Coverage Article (LCA) 
- Wheelchair Options/Accessories - Policy Article (A52504) - Effective January 1, 2020. 
 
The rules say that elevating legrests (E0990, K0195) are covered if: 
1. The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree 
flexion at the knee; or 
2. The beneficiary has significant edema of the lower extremities that requires an elevating legrest; or 
3. The beneficiary meets the criteria for and has a reclining back on the wheelchair. 
 
You can find this rule in the Local Coverage Determination (LCD) - Wheelchair Options/Accessories (L33792) 
- Effective January 1, 2020. 
 
The rules say that pneumatic tire (E2211, E2214) is a rubber tire which is used in conjunction with a separate tube (E2212, E2215) which is filled with air. You can find this rule in the Local Coverage Article (LCA) 
- Wheelchair Options/Accessories - Policy Article (A52504) - Effective January 1, 2020. 
 
The rules say that a flat free insert (E2213) is a removable ring of firm material that is placed inside of a 
pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured. This code may 
not be used for a foam filled tire. You can find this rule in the Local Coverage Article (LCA) - Wheelchair 
Options/Accessories - Policy Article (A52504) - Effective January 1, 2020. 
 
The rules say that code E2201 describe a seat width and/or depth of 20 inches or more for manual 
wheelchairs. You can find this rule in the Local Coverage Article (LCA) - Wheelchair Options/Accessories - 
Policy Article (A52504) - Effective January 1, 2020. 
 
The rules say that a non-standard seat width and/or depth for a manual wheelchair (E2201) is covered only if 
the beneficiary's physical dimensions justify the need. You can find this rule in the Local Coverage 
Determination (LCD) - Wheelchair Options/Accessories (L33792) - Effective January 1, 2020. 
 
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.