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 Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for 
a person who meets the following criteria:  
 
1. The person must have a personal mobility deficit;  
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such 
as toileting, feeding, grooming and bathing in customary locations within the home;  
3. The persons condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and 
4. The person must be capable of safely operating the PMD.  
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B). 
 
The rules say all of the following basic criteria (A-C) must be met for a power mobility device (K0800, K0801, 
K0802, K0806, K0807, K0808, K0812, K0813, K0814, K0815, K0816, K0820, K0821, K0822, K0823, 
K0824, K0825, K0826, K0827, K0828, K0829, K0835, K0836, K0837, K0838, K0839, K0840, K0841, 
K0842, K0843, K0848, K0849, K0850, K0851, K0852, K0853, K0854, K0855, K0856, K0857, K0858, 
K0859, K0860, K0861, K0862, K0863, K0864, K0868, K0869, K0870, K0871, K0877, K0878, K0879, 
K0880, K0884, K0885, K0886, K0890, K0891, K0898) 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: 
        a. Prevents the beneficiary from accomplishing an MRADL entirely, or 
        b. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to 
the attempts to perform an MRADL; or 
        c. 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. 
        a. 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. 
        b. An optimally configured manual wheelchair is one with an appropriate wheelbase, device weight, 
seating options, and other appropriate nonpowered accessories. 
 
A Group 3 PWC with Single Power Option (K0856, K0857, K0858, K0859, K0860) or with Multiple Power 
Options (K0861, K0862, K0863, K0864) is covered if: 
 
    A. The Group 3 criteria IV(A) and IV(B) are met; and 
    B. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options (criteria III[A] and 
III[B]) (respectively) are met. 
 
If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion V(A) or (V)(B) 
is not met, it will be denied as not reasonable and necessary. 
 
You can find this rule 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.