Medicare Coverage Requirements: DMEPOS
35 federal coverage criteria from Medicare LCD: Power Mobility Devices, with CMS page references. These are the Medicare requirements used when evaluating denial reasoning.
LCD L33789 (2025) (22 pages)
A power mobility device is covered when the beneficiary has a mobility limitation that significantly impairs their ability to participate in one or more mobility-related activities of daily living (MRADLs) in the home, and a PMD is determined to be medically necessary.
p. 1Billing Pathway
Determine how this DMEPOS claim should be billed based on patient location and Part A status.
If the beneficiary is currently in a covered Part A SNF stay, most DMEPOS items are included in the SNF's consolidated billing payment (42 CFR 411.15(p)). The DME supplier bills the SNF, not Medicare. If Part A is exhausted or does not apply, the supplier bills Medicare Part B directly.
Certain DMEPOS items are excluded from SNF consolidated billing and may be billed directly to Medicare Part B even during a covered Part A stay. These include customized prosthetic devices, certain orthotics, and items specifically excluded by regulation.
Mobility Limitation
The beneficiary must have a mobility limitation in the home.
Per LCD coverage criteria (L33789), 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): toileting, feeding, dressing, grooming, and bathing. The F2F must demonstrate the mobility limitation in the home specifically.
16% of PMD non-affirmations: F2F doesn't demonstrate mobility limitation in home.
The mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker. The F2F must document why a cane or walker is insufficient, not just that the beneficiary prefers a PMD.
30.3% of PMD non-affirmations: F2F doesn't demonstrate cane/walker is insufficient.
Device Justification
The specific device type must be justified based on clinical need.
Scooter vs power wheelchair determination: if a scooter (POV) is requested, the beneficiary must have sufficient upper extremity function to operate the tiller steering. If a power wheelchair is requested, the documentation must establish why a scooter is not appropriate.
72% of PMD non-affirmations involve the scooter vs wheelchair determination.
If a power wheelchair is requested, 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.
The F2F examination must document the beneficiary's upper extremity function sufficient to operate the requested PMD. For power wheelchairs: ability to operate a joystick or alternative drive control. For scooters: ability to operate tiller steering and hand controls.
35% of PMD non-affirmations: F2F doesn't demonstrate upper extremity function.
The beneficiary must be able to safely operate the power mobility device, or have a caregiver who is able and willing to operate the device on their behalf.
The beneficiary's home must provide adequate access for the device (doorway widths, turning radius, floor surfaces).
Failed Less Costly Alternatives
Documentation that less costly mobility options were considered and are insufficient.
A cane or walker has been considered and ruled out because the beneficiary is unable to use them safely and effectively due to the nature of the mobility limitation.
If a power wheelchair is requested, a manual wheelchair has been considered and ruled out because the beneficiary does not have sufficient upper extremity function to self-propel.
Required only for power wheelchair requests, not scooters.
POV-Specific Criteria
Additional coverage criteria for Power Operated Vehicles (scooters). Criteria D-I per LCD L33789.
The beneficiary is able to safely transfer to and from the POV, operate the tiller steering system, and maintain postural stability and position while operating the POV in the home.
Noridian JD: 6% non-affirmation rate for safe transfer; 5% for tiller steering. POV only.
The beneficiary's mental capabilities (cognition, judgment) and physical capabilities (vision) are sufficient for safe mobility using a POV in the home.
POV only.
The beneficiary has not expressed an unwillingness to use a POV in the home.
POV only. Beneficiary willingness is a coverage requirement.
PWC-Specific Criteria
Additional coverage criteria for Power Wheelchairs. Criteria J-O per LCD L33789.
The beneficiary does not meet coverage criterion D, E, or F for a POV (cannot safely transfer, operate tiller, or home does not accommodate a POV).
PWC only. Must document why a POV is not appropriate.
The beneficiary has the mental and physical capabilities to safely operate the power wheelchair; or if unable, a caregiver is available, willing, and able to safely operate it.
PWC only.
Use of a power wheelchair will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it in the home.
PWC only.
The beneficiary has not expressed an unwillingness to use a power wheelchair in the home.
PWC only. Beneficiary willingness is a coverage requirement.
Face-to-Face Examination
A qualifying face-to-face exam must be performed and documented.
The treating practitioner who completes the face-to-face requirements must be the same practitioner who writes the order/prescription for the PMD (base item).
The face-to-face encounter must be conducted within six (6) months prior to the order date on the WOPD for the PMD (base item).
The report of the face-to-face encounter should provide information relating to the beneficiary's mobility limitation, history of the present condition, and physical exam findings.
Specialty Evaluation
A specialty evaluation for certain PWC types and power assist systems.
The specialty evaluation that is required for beneficiary's who receive a Group 2 Single Power Option or Multiple Power Options PWC, any Group 3 PWC, or a power assist system is in addition to the requirement for the face-to-face encounter.
The specialty evaluation provides detailed information explaining why each specific option or accessory (power seating system, alternate drive control interface, or power assist system) is needed to address the beneficiary's mobility limitation. There must be a written report of this evaluation available on request.
Home Assessment
On-site home assessment documenting device accessibility.
An on-site evaluation of the beneficiary's home must document adequate access between rooms, maneuvering space, and surfaces for the operation of the power mobility device.
The home assessment report must document specific measurements: doorway widths, hallway widths, turning radius at key locations, floor surface types, and any accessibility barriers or modifications.
LCMP Concurrence
Physician concurrence when LCMP examination is part of the F2F.
If the report of a licensed/certified medical professional (LCMP) examination is to be considered as part of the F2F, there must be physician concurrence or disagreement with the LCMP examination.
Applies when PT/OT conducts mobility evaluation as part of the F2F encounter.
RESNA ATP
RESNA-certified ATP involvement for applicable wheelchair groups.
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.
Required for Group 2 SPO/MPO, any Group 3, Group 5, and push-rim power assist.
The PT, OT, or practitioner performing the specialty evaluation may have no financial relationship with the supplier.
Written Order Prior to Delivery (WOPD)
A standard written order is required prior to delivery for PMD base items.
Power Mobility Device bases require a Standard Written Order (SWO) prior to delivery (WOPD) for the base item.
The WOPD for the base item may only be written after the completion of the face-to-face encounter requirements.
The treating practitioner who completes the face-to-face requirements must be the same practitioner who writes the order/prescription for the PMD (base item).
If the supplier does not receive the order/prescription for the base item prior to delivery, the claim will be denied as not reasonable and necessary.
The WOPD for the base item must be written on or after the date of the face-to-face encounter.
Order Forwarding Timeline
The 7-element order must reach the supplier within 45 days of the face-to-face encounter.
For power mobility devices, the 7-element order must be forwarded to the supplier within 45 calendar days after the face-to-face encounter is completed.
Order Before Delivery
The written order must be received by the supplier before the equipment is delivered.
The supplier must receive the completed standard written order (WOPD) before delivering the power mobility device to the beneficiary.