Power Wheelchair Medicare Funding Guide

The provision of Mobility Assistive Equipment (MAE) under Medicare is a complex, multi-step process. To qualify a patient for coverage and reimbursement, providers must follow specific guidelines outlined in the National Coverage Determination (NCD) for MAE. This includes a decision-making algorithm that spans from walking aids to power wheelchairs, requiring that lower levels of technology be ruled out before qualifying for a more advanced device.

This guide is a quick reference and not a substitute for the full Medicare policy as related to adult complex rehab power wheelchairs. Providers must review the Local Coverage Determination (LCD) and associated Policy Articles for each recommended item.

Key Characteristics Influencing Power Wheelchair Selection

While Medicare's policy for power wheelchairs is diagnosis-driven, it is not solely based on ICD-10 codes. A qualifying diagnosis alone is not sufficient. Providers must assess:

• Routine environments (home and community)
• Daily activities, roles, and responsibilities

When selecting a power wheelchair, consider the following components to meet the individual's medical and functional needs and determine corresponding qualifications.

1. Power Wheelchair (PWC) Base
   • See below for various group performance characteristics and features
   • Power Mobility Device (PMD) policy article A52498 defines a power wheelchair as "Chair-like battery powered mobility device for people with difficulty walking due to illness or disability, with integrated or modular seating system, electronic steering, and four or more wheel non-highway construction."
2. Power Wheelchair Drive Wheel Configuration
   • Front, Rear, Mid-wheel: denotes the location of the main drive wheels in relation to where the rider is sitting, which impacts performance and maneuverability. Learn more in this resource.
3. Seating Type
   • Sling or Solid Base (Rehab Seat)
     • Requires additional seat/back cushions
     • Must have a documented medical need
     • ICD-10 driven: If the diagnosis is not listed, the cushion will be denied
   • Captain Seat
     • No additional cushions covered
4. Power Seating Options
   • No Power: can only accept power elevating legrests and/or seat elevation
   • Single Power Option (SPO): can operate power tilt, recline, or seat elevation, but not a combination of power tilt and recline
   • Multiple Power Options: can operate a combination of power tilt and recline, as well as the ability to accommodate power elevating legrests, power seat elevation, and/or power standing system
5. Weight Capacity
   • Heavy-duty options are coded differently and require justication

What's the need for additional options/accessories and positioning components?

The Wheelchair Basic Equipment Package outlines the standed components included with every initial power wheelchair, which cannot be billed separately unless specified. These include items like a lap belt, battery charger, tires/casters, legrests, footrests, armrests, components tailored to the user's weight and size, and a non-expandable controller/standard proportional joystick. Some upgrades (such as elevating legrests, adjustable armrests, larger seat/back dimensions for certain power wheelchair groups, expandable controller, non-standard joystick/alternative drive control) may be billed separately, but this does not guarantee coverage.

1. Electronics and Controls: Advanced electronics and alternative drive inputs
2. Seating: Skin protection, positioning, combination, custom, etc.
3. Positioning Components: Headrests, lateral pads, thigh/knee pads, arm troughs, etc.

Categories of Power Mobility Devices

There are various types of Powerr Mobility Devices tailored to individual needs. A Specialty Evaluation helps determine the necessary performance characteristics to meet the patient's goals. To differentiate the performance characteristics, power mobility devices have been broken down into five power wheelchair and two Power Operated Vehicle (POV) Groups and further subdivided based on beneficiary weight capacity, seat type, portability, and/or power seating capability. Understanding routine activities, roles, and responsibilities will help define necessary wheelchair performance and influence selection.

The focus of this resource is to differentiate between Group 2, 3, and 4 power wheelchairs and the specific components required for justification and documentation to meet the criteria for coverage according to Medicare guidelines.

Powered Mobility Device (PMD) Groups

Group 2, 3, and 4 Power Wheelchair Base General Performance Characteristics

Power Wheelchair Base Subdivision Features

* Non-expandable controller: standard proportional joystick only; can control up to two power seating actuators through the drive control and accommodate attendant control

** Expandable controller: accommodates specialty input devices and can control three or more powered seating actuators through the drive control

Group 3 Power Wheelchair HCPCS Codes

Note: Seat options and weight capacities are listed in the HCPCS code descriptor

Power Wheelchair Evaluation and Justification

With a better understanding of the options, including performance characteristics of a power wheeelchair, a Specialty Evaluation is needed to match the power wheelchair and the selected components to the client's medical and functional needs to justify coverage.

The Wheeled Mobility and Seating Evaluation tool was updated in 2024. This version includes enhanced evaluation and justification details based on peer-reviewed research, supports innovative product designs, and addresses third-party payor denials. It also clearly outlines areas that may be completed by the supplier Assistive Technology Professional (ATP) as part of the team-based evaluation process. In addition, new clinician and supplier attestations have been added to confirm that improper practices, such as scribing, have not occured.

Power Wheelchair Medicare General Coverage Criteria

To qualify for a power wheelchair, the following conditions must be met:

• Mobility limitation that impairs the ability to participate in at least one mobility-related activity of daily living.
• The mobility limitation cannot be resolved using a cane, crutches, or walker.
• A manual wheelchair is not an option due to limitations of strength, endurance, range of motion, coordination, presence of pain, deformity, or the absence of one or both upper extremities, and is relevant to the upper extremity funciton. Even an optimally configured manual wheelchair is not sufficient to allow the person to operform mobility-related activities of daily living during their typical day.
• Lower-level equipment should be trialed or ruled out, with documentation specifying why these options do not meet the individual's needs (e.g., scooter or Group 2 power wheelchair).
• The individual has the willingness and ability to physically and safely operate the recommended device.
  • If the beneficiary is unable to safely operate the power wheelchair, the beneficiary has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided.
• The beneficiary's weight is less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class power wheelchair.
• The individual's home is accessible for the operation of the power wheelchair.
  • Medicare requires the power wheelchair to be medically necessary to complete MRADLs inside the home. Other funding sources may consider the need for outside the home.

Additional Coverage Criteria for Group 2 Power Wheelchairs

Additional Coverage Criteria for Group 3 Power Wheelchairs

Seat Elevation Coverage

In 2023, Medicare announced coverage for power seat elevation, or a "seat elevator," which is an optional function available on power wheelchairs. It allows the rider to remain supported in a seated position and use their controls to raise the vertical height of their seating system on the power chair base. The application and benefits are well documented and supported by RESNA and many other groups in the Complex Rehabilitation Technology industry.

Power seat elevation is a seating function that can enhance independence, maximize function, increase safety, and protect against pain and injury for the power wheelchair rider. Documentation that includes relevant and applicable subjective and objective assessment findings is essential for justifying your patient's need for power seat elevation and contributes to a successful outcome.

Coverage criteria for power seat elevation

1. Requires a specialty evaluation by a Licensed/Certified Medical Professional (LCMP) that confirms the individual's ability to safely operate seat elevation equipment in the home
   and
2. At least one of the following applies:
   1. The individual performs weight-bearing transfers to/from the power wheelchair while in the home, using either their upper extremities during a non-level (uneven) sitting transfer and/or their lower extremities during a sit-to-stand transfer. Transfers may be accomplished with or without caregiver assistance and/or the use of assistive equipment (e.g., sliding board, cane, crutch, walker, etc.); or,
   2. The individual requires a non-weight-bearing transfer (e.g., a dependent transfer) to/from the power wheelchair while in the home. Transfers may be accomplished with or without a fllor or mounted lift; or,
   3. The individual performs reaching from the power wheelchair to complete one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations within the home. MRADLs may be accomplished with or without caregiver assistance and/or the use of assistive equipment.

Stakeholders and Their Roles in Power Wheelchair Documentation

Client / Caregiver

Role: Provide detailed personal context and needs

Responsibilities:

• Describe daily activities and how mobility technology will help
• Explain current equipment and its limitations
• Detail routine environments (e.g., home, outdoor surfaces)
• Share transportation methods (public / private)

Treating Practitioner (physician, PA, NP, CNS)

Role: Medical authority responsible for initiating and validating the process

Responsibilities:

• Complete face-to-face examination
• complete Written Order Prior to Delivery (WOPD)
• Review and sign Standrd Written Order (SWO)

Licensed / Certified Medical Professional (LCMP, e.g., PT, OT, or another mobility-trained practitioner without financial ties to the supplier)

Role: Conducts the Specialty Evaluation

Responsibilities:

• Document medical and functional limitations
• Provide objective, specific descriptions of the individual
• Paint a clear picture of the person's needs and environment
• Justify all recommended components and seating
• Avoid vague or repetitive policy language

RESNA-Certified ATP (Assistive Technology Professional)

Role: Supplier assisting in technology selection and documentation

Responsibilities:

• List manufacturer / model for each component
• Provide technical justifications for selections (e.g., head support fit, legrest configuration)
• Record measurements for wheelchair and components
• Document environmental limitations affecting choices
• Ensure complete and accurate documentation before submission for prior authorization and/or payment (Face-to-Face, WOPD, SWO, medical records)
  • Use DME MAC checklists to streamline review
• Ensure correct coding
• Maintain proof of delivery

Policy-Specific Documentation Requirements

Power wheelchairs have additional policy-specific requirements that must be met prior to Medicare reimbursement. The following chart outlines the documentation components, descriptions, responsible parties, and timelines for completing & submitting the documentation.

Tips for Documenting Medical Need for Power Wheelchairs

Paint a full picture

Include a detailed, individualized information:

• Physical evaluation findings relevant to the technology
• Trials or simulations: successes and failures
• Functional needs and limitations
• Daily tasks, roles, and responsibilities
• Routine environments (home, community, transportation)
• Current equipment:
  • What works and what doesn't
  • Why replacement is necessary

Start and end with "why"

• Ask "Why is this technology neccessary?"
• Keep asking "why" until the answer is clear, specific, and justified
• Ensure the final documentation:
  • Clearly explains why each component is needed
  • Is objective
  • Gives reviewers a complete picture of the person's needs

Use objective language, not subjective

Subjective language is vague and open to interpretation. Objective language is measurable, specific, and evidence-based. Examples:

Summary

Securing funding for complex rehabilitation technologies involves a multi-step process that engages various healthcare professionals, each with specific roles and responsibilities. A clear understanding of this process (as well as the associated documentation requirements) enables clinicians and suppliers to help clients obtain the most appropriate equipment for their individual mobility needs. Thorough and timely completion of all necessary documentation can also minimize delays and improve efficiency throughout the procurement process.

This guide is designed as a resource to assist with this process. However, clinicians and suppliers should familiarize themselves with the Local Coverage Determination (LCD) and related Policy Article for each of the items being recommended in order to obtain a thorough understanding of the Medicare rules and regulations governing mobility assistive equipment. See below for links to helpful resources regarding coverage criteria for power mobility.

Power Mobility Resouces

• DME MAC Jurisdiction B Supplier Manual Coverage and Medical Policy Chapter 9. CGS Medicare. (2025). https://www.cgsmedicare.com
• Local Coverage Determination (LCD) Power Mobility Devices. CMS.gov. (2023, May 16). https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=33789&ver=35
• Medicare Prior Authorization for Certain Power Mobility Devices and Accessories. CGS Medicare. (2024, August). https://www.cgsmedicare.com
• Mobility Assistive Equipment (MAE) - National Coverage Determination (NCD). CMS.gov. (2005, July 5). https://www.cms.gov
• Power Mobility (Group 3) Documentation Checklist. CGS Medicare. (2020, May 12). https://www.cgsmedicare.com
• Power Mobility Devices - Policy Article. CMS.gov. (2023, May 16). https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52498&ver=59
• Power Mobility Devices – Medical Review. CGS Medicare. https://www.cgsmedicare.com
• RESNA Position on the Application of Seat Elevation Devices for Power Wheelchair Users. RESNA.org. (2019, September 25). https://www.resna.org
• Seat Elevation Systems as an Accessory to Power Wheelchairs (Group 3) - National Coverage Analysis (NCA), Proposed Decision Memo. CMS.gov. (2023, February 15). https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=Y&NCAId=309
• Standard documentation requirements for all claims submitted to DME MACs - Article. CMS.gov. (2024, January 1). https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=55426&ver=123
• Wheelchair Options/Accessories - Policy Article. CMS.gov. (2025, April 1). https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=52504

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