Why power wheelchair claims get denied
Most denials are not a judgment about you. They are a judgment about a document. The coverage policy names, in its own lettered sections, which document and what it has to say.
Where this comes from
Based on Medicare Local Coverage Determination L33789 — Power Mobility Devices, revision effective . Coverage policy is revised periodically. Confirm current requirements against the CMS Medicare Coverage Database before relying on this. This page is information, not medical or legal advice, and does not determine whether you qualify for anything.
Denials happen at a letter
The rules Medicare applies to a power mobility device (PMD) live in a Local Coverage Determination — an LCD, written by the contractor that processes the claim. It is a lettered list. General criteria A, B and C. Scooter criteria D through I. Power wheelchair criteria (a)–(b) and J through O. Roman numerals for the option groups, and named sections for the paperwork and the dates.
A denial lands on one of those letters. Being able to say we were denied at C is worth more than any general complaint, because it is the vocabulary the doctor's office, the supplier and the auditor already use.
Each block below carries its letter in the margin and its citation underneath. The red-ruled note that closes each block is the consequence recorded against that requirement, reproduced word for word from our transcription and never rewritten. Two of them also record how often auditors find the requirement missing, which is an observation about audits rather than a rule in the determination. Follow the citation to read the determination itself.
The failures the policy itself flags
The face-to-face visit fell outside the six months before the order
Every power mobility claim rests on a face-to-face (F2F) encounter — a visit, in person, about how you get around. The policy puts that visit inside a window.
The face-to-face visit about how you get around has to fall in the six months before the date on the order. Not after it, and not longer than six months before it. Check both dates yourself — this is one of the most common things auditors find.
A note dated outside the window does not become inside it. What the policy asks for is an encounter in the six months before the order date, so what closes the gap is a new visit and an order dated after it.
An out-of-window face-to-face is one of the most common audit findings on PMD claims.
Someone other than the practitioner who examined you wrote the order
The written order that has to reach the supplier before the chair is delivered is called a written order prior to delivery — a WOPD.
The practitioner who did the face-to-face visit has to be the same one who signs the order. Not a colleague in the same office, not whoever is covering that week. This one is federal law, not only coverage policy, so nobody can waive it.
It is worth asking, out loud, at the visit: will you be the one writing the order? An office that shares mobility paperwork across providers is not doing anything careless — it is doing what works for most other orders, and this order is the exception.
A WOPD written by a different practitioner than the one who performed the F2F does not satisfy the statute.
No one measured the home, or the chair cannot be driven in it
Someone has to check your home against the exact chair being ordered and write down doorway widths, turning space, thresholds and floor surfaces. When a chair cannot physically be driven in the home, this is the paperwork auditors go to first.
Two separate things fail here. One is that the measurements were never written down. The other is that they were, and the chair does not fit — a doorway narrower than the chair's base, a hallway with no room to turn, a step at the only entrance. The second is not fixed by paperwork. It is fixed by choosing a chair that fits the home, or by changing the home, and it is far cheaper to find out before delivery than after.
The most common audit finding when a PMD cannot physically operate in the home. Denied as not reasonable and necessary if this criterion is not met.
Nothing in writing rules out a cane or a walker
Your note has to answer one question in writing: why will a cane or a walker, fitted properly for you, not be enough at home? “The patient would prefer a wheelchair” is not an answer to that question.
This is not a test anyone is trying to catch you on. Coverage runs in order, and the note has to walk down that order in writing. A record that jumps straight to a power chair has skipped a step the reviewer is required to look for.
The LCD requires cane/walker to be ruled out. Denied as not reasonable and necessary if this criterion is not met.
Nothing in writing rules out a manual wheelchair
Your note has to describe what your arms and shoulders can actually do — strength, how long before they tire, how far they move, pain, coordination — and why pushing a manual wheelchair around your home all day is not realistic for you.
The phrase the policy uses is during a typical day. Managing a few pushes in an exam room is not the question. What you can still do at the end of an ordinary day at home is.
Manual wheelchair must be ruled out on documented upper-extremity findings. Denied as not reasonable and necessary if this criterion is not met.
The scooter was never ruled out
The policy's name for a scooter is a power-operated vehicle, or POV. It sits one rung below a power wheelchair (PWC), so it has to be considered and set aside before a power chair is on the table.
Before a power wheelchair, your note has to show a scooter was considered and say why it will not work for you at home — getting on and off it, steering it, sitting upright in it, or getting it through your rooms.
A PWC is only covered once a POV has been ruled out on documented grounds. Denied as not reasonable and necessary if this criterion is not met.
The chair arrived before the order was signed
The written order has to be signed and dated by your practitioner before the chair is delivered. The paperwork calls this a WOPD — a written order prior to delivery. If the supplier delivers first and collects the order afterwards, the claim is denied.
This one is entirely in the supplier's hands, and it is fair to ask them directly: do you have the signed order in front of you before you schedule delivery?
If the supplier does not receive the order for the base item prior to delivery, the claim WILL be denied as not reasonable and necessary.
The order was signed and dated, but one of its six elements is missing
Since 1 January 2020 every Medicare order for equipment is the same standard written order, and it has to carry six things: the beneficiary’s name or MBI, a description of the item, the quantity where that applies, the order date, the practitioner’s name or NPI, and the practitioner’s signature.
An order can look complete, be signed by the right person and still fail because one of the six is absent. Offices working from an older “seven-element order” template are especially prone to it: the form asks for things that are no longer required and does not ask for one or two that are.
It compounds with the requirement above. Because the order also has to reach the supplier before delivery, a corrected order signed later carries a later date — and the delivery is then ahead of the order.
An order missing any of the six is not a valid order, and the claim is denied on the documentation rather than on anything clinical.
Group 3 chairs: three more places to fail
Group 3 is the specialty level of power wheelchair. On top of everything above, the policy adds three requirements — the cause the record has to establish, an independent specialty evaluation, and a certified Assistive Technology Professional (ATP) present when the chair is chosen — and a claim can clear A through O and still stop at any one of them.
The record does not establish the cause the policy asks about
Group 3 chairs are for people whose trouble moving comes from a condition of the nerves or brain, a disease of the muscles, or a difference in the bones present from birth. Your doctor is the one who decides and writes down whether that fits your situation. You do not have to name anything yourself.
A Group 3 PWC is denied as not reasonable and necessary if criteria IV(A)–(D) are not met. This is the criterion that distinguishes Group 3 from Group 2.
The specialty evaluation is missing, unsigned, or done by someone tied to the supplier
A physical therapist, an occupational therapist, or a practitioner trained in wheelchair evaluations has to examine you and write a signed, dated report on why this chair and its features are needed. That person cannot have a money relationship with the company supplying the chair, and the file has to say so.
The financial-independence part is the half that gets forgotten. A therapist employed by the supplier can be excellent at the job and still make the report unusable for this claim.
Missing or financially-conflicted specialty evaluation. Denied as not reasonable and necessary if this criterion is not met.
No certified Assistive Technology Professional was in the room when the chair was chosen
The company supplying the chair has to employ an ATP — an Assistive Technology Professional, certified by RESNA, the Rehabilitation Engineering and Assistive Technology Society of North America — who specializes in wheelchairs. That person has to be with you in person while your chair is chosen. Their current certificate and a record of their involvement both go in the file.
This is a question to ask a supplier before you start, not after: do you employ a RESNA-certified ATP, and will they be there in person?
Missing ATP involvement or credential. Denied as not reasonable and necessary if this criterion is not met.
Group 4 chairs: not a paperwork gap
A Group 4 chair supplied for use in the home
Medicare will not pay for a Group 4 chair for use inside the home. Better paperwork does not change this — the policy states that a Group 4 chair supplied for use in the home will be denied. If one is still being ordered, ask the supplier for an ABN, an Advance Beneficiary Notice: the form that tells you in writing what you would owe before you agree to anything.
Every other block on this page describes something that can be written differently. This one does not. The policy's position is about the equipment class and in-home use, so a stronger note, a longer evaluation and a better letter all land in the same place.
If a Group 4 PWC is provided it WILL be denied as not reasonable and necessary. This is categorical, not a documentation gap.
Knowing this early is the point of putting it here. It is not a reason to stop. Ask your evaluator and your supplier which group the chair you actually need falls into, and what a Group 3 chair with the right seating and controls would do for the tasks that are hard at home. Ask for the ABN in writing before anything is delivered, so the cost is a decision you make rather than a bill you receive.
If you have already been denied
Start with the notice. It names a reason, and that reason usually maps onto one of the letters above.
- Find the reason on the notice and match it to a letter on this page. Write the letter down. It is the fastest way to be understood by the office and the supplier.
- Check the two dates yourself. The date of the face-to-face visit, and the date on the order. The visit has to fall in the six months before the order.
- Check who signed. The name on the face-to-face note and the name on the order have to be the same practitioner.
- Ask for a specific document, not for “more information”. A home assessment that was never done can still be done. An upper-extremity examination that was never written down can be written down at a new visit.
- Ask the supplier what they hold. The written order before delivery, the ATP's certificate, the specialty evaluation and the home assessment often sit with the supplier rather than the doctor's office.
- Bring a checklist to the next appointment. Get ready for your appointment builds one you can hand over, with a page for you and a page for the office.
The notice you received also explains how to appeal and by when. Read it for those steps. Appeal deadlines are not part of the coverage policy this page quotes, and this page does not restate them.