Get ready for your appointment

Eleven questions in plain language, and then a sheet you can print: one page for you, one page for your doctor's office. Nothing you answer leaves this browser.

Where this comes from

Based on Medicare Local Coverage Determination L33789 — Power Mobility Devices, revision effective October 1, 2025. 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.

Options and accessories criteria come from a second determination, L33792 — Wheelchair Options/Accessories, which carries its own revision history. Confirm it in the same database.

What the sheet is

Part 1 is for you. Your own answers, written back as sentences you can say out loud, in the order the appointment usually goes, with ruled lines to add anything else you want to raise.

Part 2 is for your doctor's office. The documentation checklist, quoted in the coverage policy's own words, each item carrying its section reference and the sentence recorded against it about what happens when that documentation is not in the record. Two of those sentences also record how often auditors find the requirement missing, which is an observation about audits rather than a rule in the determination.

The sheet does not say whether you qualify for anything, and neither does anything else on this site. Your practitioner makes the clinical determination, and the payer decides coverage. What the sheet does is make sure the appointment covers what the record has to cover.

Your answers stay in this browser tab. There is no server to receive them, no account, and nothing is written into the web address. Closing the tab clears them, and the button marked Clear my answers clears them straight away. More about what this site does not collect.

The abbreviations in the quoted policy text

The requirements on this page are quoted exactly as the coverage policy writes them, abbreviations and all, because a paraphrase stops being the quotation. Here is what each one stands for.

LCD — Local Coverage Determination, the coverage rules written by the contractor that processes the claim.
PMD — power mobility device, meaning a scooter or a power wheelchair.
POV — power-operated vehicle, the policy's name for a scooter.
PWC — power wheelchair.
MRADL — mobility-related activity of daily living: using the toilet, eating, getting dressed, grooming, bathing.
F2F — face-to-face, the in-person visit about how you get around.
WOPD — written order prior to delivery, the signed order the supplier has to hold before anything arrives.
SWO — standard written order, the order form itself.
ATP — Assistive Technology Professional, certified by RESNA, the Rehabilitation Engineering and Assistive Technology Society of North America.

Where to go next

If you already have a denial notice in front of you, start with the reasons instead — each one is matched to the section of the policy it comes from.

Why claims get denied For my doctor's office What Medicare covers

The complete checklistEvery requirement in the coverage policy, in policy order, with nothing narrowed. Take it to the appointment as it is, or read it alongside the notice you already have.Everyone: the three general criteria

L33789 General Coverage Criteria (A)

General Coverage Criteria (A)

Your note has to name the everyday things at home that are hard, unsafe, or take far too long because of how you move around — using the toilet, eating, getting dressed, grooming, bathing. Not only that walking is hard — which task, in which room, and what happens when you try.

What has to be in the record: Face-to-face encounter note describing the mobility limitation and how it interferes with MRADLs (toileting, feeding, dressing, grooming, bathing) in customary locations in the home.

If this is missing

A PMD is not covered without a qualifying mobility limitation. Denied as not reasonable and necessary if this criterion is not met.

L33789 General Coverage Criteria (B)

General Coverage Criteria (B)

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.

What has to be in the record: F2F note answering: why can a cane or walker not meet this beneficiary’s mobility needs in the home?

If this is missing

The LCD requires cane/walker to be ruled out. Denied as not reasonable and necessary if this criterion is not met.

L33789 General Coverage Criteria (C)

General Coverage Criteria (C)

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.

What has to be in the record: Examination findings on upper extremity strength, endurance, ROM, coordination and pain; and why an optimally-configured manual wheelchair is not sufficient.

If this is missing

Manual wheelchair must be ruled out on documented upper-extremity findings. Denied as not reasonable and necessary if this criterion is not met.

If a scooter is being considered

L33789 POV Criteria (D)

POV Criteria (D)

For a scooter, your note has to say whether you can get on and off it safely, work the tiller — the steering handle you hold and turn — and stay sitting upright while you drive it around your home.

What has to be in the record: F2F note addressing transfer ability, tiller operation and postural stability.

If this is missing

POV denied if criteria A–I are not met. Denied as not reasonable and necessary if this criterion is not met.

L33789 POV Criteria (E)

POV Criteria (E)

For a scooter, your note has to address your thinking, your judgment and your eyesight, and say whether they are up to driving one safely inside your home.

What has to be in the record: Cognitive and visual assessment supporting safe POV operation.

If this is missing

POV denied if criteria A–I are not met. Denied as not reasonable and necessary if this criterion is not met.

L33789 POV Criteria (F)

POV Criteria (F)

For a scooter, someone has to look at your home and write down the doorway widths, how much room you have to turn, and what the floors are like. Measurements, not “home is accessible”.

What has to be in the record: Home assessment documenting doorway widths, turning space and floor surfaces.

If this is missing

POV denied if criteria A–I are not met. Denied as not reasonable and necessary if this criterion is not met.

L33789 POV Criteria (G)

POV Criteria (G)

Your note has to state your weight, and the paperwork has to show the scooter is rated to carry it. The policy sets the classes by weight: heavy duty 285–450 lb, very heavy duty 428–600 lb.

What has to be in the record: Documented beneficiary weight and the weight capacity of the POV supplied.

If this is missing

A POV outside the listed weight range is denied as not reasonable and necessary.

L33789 POV Criteria (H)

POV Criteria (H)

Your note has to connect the scooter to specific things you do at home — which tasks it lets you get back to — and say you will use it inside the house, not only outdoors.

What has to be in the record: F2F note linking the device to specific MRADLs performed in the home.

If this is missing

POV denied if criteria A–I are not met. Denied as not reasonable and necessary if this criterion is not met.

L33789 POV Criteria (I)

POV Criteria (I)

Your note has to record that you are willing to use a scooter at home. If you have told anyone you would not use one, that belongs in the record and needs talking through first.

What has to be in the record: Note recording the beneficiary’s willingness to use the device in the home.

If this is missing

POV denied if criteria A–I are not met. Denied as not reasonable and necessary if this criterion is not met.

If a power wheelchair is being considered

a–b

L33789 PWC Criteria (a)–(b)

PWC Criteria (a)–(b)

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, whether your thinking, judgment and eyesight make it safe for you to drive one, or getting it through your rooms.

What has to be in the record: F2F note answering: why can a POV (scooter) not meet this beneficiary’s mobility needs in the home?

If this is missing

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.

J/K

L33789 PWC Criteria (J)/(K)

PWC Criteria (J)/(K)

Your note has to say who will drive the chair. If that is you, it has to say you can do it safely. If someone who cares for you will drive it, the note has to name that person, say they are available, willing and able to drive it safely, and say they cannot push a manual wheelchair for you instead.

What has to be in the record: Assessment of the beneficiary’s ability to operate the PWC safely in the home, or documentation of the caregiver who will.

If this is missing

PWC denied if criteria (a)–(e) are not met. Denied as not reasonable and necessary if this criterion is not met.

L33789 PWC Criteria (L)

PWC Criteria (L)

Your note has to state your weight, and the paperwork has to show the chair is rated to carry it. The policy sets the classes by weight: heavy duty 285–450 lb, very heavy duty 428–600 lb, extra heavy duty 570 lb and up.

What has to be in the record: Documented beneficiary weight and the weight capacity of the PWC supplied.

If this is missing

A PWC outside the listed weight range is denied as not reasonable and necessary.

L33789 PWC Criteria (M)

PWC Criteria (M)

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.

What has to be in the record: Home assessment documenting doorway widths, turning radius, thresholds and floor surfaces for the specific chair supplied.

If this is missing

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.

L33789 PWC Criteria (N)

PWC Criteria (N)

Your note has to connect the chair to specific things you do at home, and say you will use it inside the house. If you need help from someone to do those things, the note can say that.

What has to be in the record: F2F note linking the chair to specific MRADLs performed in the home.

If this is missing

PWC denied if criteria (a)–(e) are not met. Denied as not reasonable and necessary if this criterion is not met.

L33789 PWC Criteria (O)

PWC Criteria (O)

Your note has to record that you are willing to use a power wheelchair at home.

What has to be in the record: Note recording the beneficiary’s willingness to use the device in the home.

If this is missing

PWC denied if criteria (a)–(e) are not met. Denied as not reasonable and necessary if this criterion is not met.

L33789 Group 4 PWCs

Group 4 PWCs

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.

What has to be in the record: If a Group 4 chair is being supplied, record why and obtain an ABN — Medicare will not cover it for in-home use.

This is categorical, not a missing document

If a Group 4 PWC is provided it WILL be denied as not reasonable and necessary. This is categorical, not a documentation gap.

Chairs with powered seating or a non-joystick way to drive

L33789 Group 2 SPO Criteria II(1)/(2)

Group 2 SPO Criteria II(1)/(2)

If the chair needs a way to drive it other than a standard joystick worked by hand or by chin — a head control, a sip-and-puff tube, switches — or the file meets the coverage criteria for a powered tilt or powered recline seat and that seat is on the chair, a specialist has to examine you and write that up. A chair at this level asked for only to get a raising seat, a standing feature, or powered legrests is denied.

What has to be in the record: Specialty evaluation documenting the alternative drive control, or the seating system criteria under the Wheelchair Options/Accessories LCD.

If this is missing

A Group 2 SPO PWC provided only to accommodate seat elevation, a power standing feature, or power elevating legrests is denied as not reasonable and necessary.

III

L33789 Group 2 MPO Criteria III(1)/(2)

Group 2 MPO Criteria III(1)/(2)

For a chair carrying more than one powered seat function, your file has to show you need powered tilt and powered recline together, or that a ventilator is mounted on the chair.

What has to be in the record: Specialty evaluation documenting the tilt-and-recline need, or documentation of the wheelchair-mounted ventilator.

If this is missing

A Group 2 MPO PWC is denied as not reasonable and necessary if III(A) or III(B) is not met.

EVAL

L33789 Specialty Evaluation (II[A]/III[A]/IV[C])

Specialty Evaluation (II[A]/III[A]/IV[C])

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.

What has to be in the record: Written specialty evaluation report, signed and dated, plus an attestation of financial independence from the supplier.

If this is missing

Missing or financially-conflicted specialty evaluation. Denied as not reasonable and necessary if this criterion is not met.

ATP

L33789 ATP Requirement (II[B]/III[B]/IV[D])

ATP Requirement (II[B]/III[B]/IV[D])

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.

What has to be in the record: The ATP’s current RESNA certificate, and documentation of their direct in-person involvement in selecting this chair for this beneficiary.

If this is missing

Missing ATP involvement or credential. Denied as not reasonable and necessary if this criterion is not met.

Group 3 chairs

IV(B)

L33789 Group 3 Criteria IV(B)

Group 3 Criteria IV(B)

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.

What has to be in the record: Diagnosis and clinical findings establishing a neurological condition, myopathy or congenital skeletal deformity as the cause of the mobility limitation.

If this is missing

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.

V(B)

L33789 Group 3 SPO/MPO Criteria V(B)

Group 3 SPO/MPO Criteria V(B)

If a Group 3 chair also carries powered seat functions or a special way to drive it, the same write-up the Group 2 version of that chair needs has to be in the file as well.

What has to be in the record: The Group 2 SPO or MPO documentation appropriate to the option level supplied.

If this is missing

A Group 3 SPO or MPO PWC is denied as not reasonable and necessary if V(A) or V(B) is not met.

Group 5 chairs, built for someone still growing

VII(B)

L33789 Group 5 Criteria VII(B)

Group 5 Criteria VII(B)

Group 5 chairs are built for a person who is still growing. Your note has to say that growth in height is expected.

What has to be in the record: Clinical documentation of expected growth supporting a pediatric (Group 5) configuration.

If this is missing

A Group 5 PWC is denied as not reasonable and necessary if criteria VII(A)–(C) are not met.

Add-ons: power-assist wheels, powered seating, a seat that raises

E0986

L33789 Power Assist E0986 (B)

Power Assist E0986 (B)

Power-assist wheels that bolt onto a manual wheelchair carry their own rule. Your record has to show that you have been pushing yourself in a manual wheelchair for at least a year.

What has to be in the record: Documentation of at least one year of self-propulsion in a manual wheelchair.

If this is missing

Power assist denied if all criteria are not met. Denied as not reasonable and necessary if this criterion is not met.

1–3

L33792 Power Tilt/Recline (1)–(3)

Power Tilt/Recline (1)–(3)

For a powered tilt or recline seat, three things have to be in the file: the paperwork that supports the power wheelchair itself, a seating and positioning evaluation by a therapist with no money relationship to the supplier, and a certified ATP — Assistive Technology Professional — who was there in person.

What has to be in the record: Seating and positioning specialty evaluation, financial-independence attestation, and the ATP credential.

If this is missing

If these criteria are not met the power seating component(s) will be denied as not reasonable and necessary.

4–6

L33792 Power Tilt/Recline (4)–(6)

Power Tilt/Recline (4)–(6)

Your note also has to give the reason the powered seat is needed. The policy accepts three: you are at high risk of a pressure sore and cannot shift your own weight; you use a catheter on a schedule and cannot get yourself from the chair to the bed; or the seat is needed to manage muscle tightness or spasms.

What has to be in the record: Clinical findings supporting the specific qualifying indication chosen.

If this is missing

If none of the three qualifying indications is documented the power seating component is denied as not reasonable and necessary.

E2298

L33792 Power Seat Elevation E2298

Power Seat Elevation E2298

A seat that raises up is judged under two rules at once: this coverage policy, and a separate national rule — NCD 280.16, a National Coverage Determination covering power seat elevation. Your file has to satisfy both, so both have to be written to.

What has to be in the record: The Group 2 SPO/MPO or Group 3 qualifying documentation, plus documentation against NCD 280.16.

If this is missing

Seat elevation is governed by both this LCD and NCD 280.16 — both must be satisfied.

Dates, orders and signatures

WOPD

L33789 Documentation Requirements — WOPD

Documentation Requirements — WOPD

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.

What has to be in the record: SWO/WOPD for the base item, signed and dated by the treating practitioner BEFORE the delivery date.

If this is missing

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.

F2F

L33789 Documentation Requirements — F2F timing

Documentation Requirements — F2F timing

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.

What has to be in the record: Dated F2F encounter note, and the WOPD date, demonstrating the encounter falls in the 6 months before the order.

If this is missing

An out-of-window face-to-face is one of the most common audit findings on PMD claims.

SAME

L33789 Documentation Requirements — same practitioner

Documentation Requirements — same practitioner

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.

What has to be in the record: F2F note and WOPD showing the same treating practitioner on both.

If this is missing

A WOPD written by a different practitioner than the one who performed the F2F does not satisfy the statute.

SWO

L33789 Documentation Requirements — accessory SWO

Documentation Requirements — accessory SWO

Anything billed separately from the chair itself — a cushion, a special headrest, added controls — needs its own written order, reviewed and signed by a treating practitioner, before the bill goes to Medicare.

What has to be in the record: SWO listing each separately-billed option/accessory, reviewed and signed by a treating practitioner.

If this is missing

Separately-billed accessories without an SWO prior to claim submission are denied.

Get ready for your appointment

Where this comes from

What the sheet is

The abbreviations in the quoted policy text

The questions

Where to go next