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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 state that 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 the beneficiary meets the coverage criteria for a power tilt and recline seating system. You can find this rule at Local Coverage Determination (LCD): Power Mobility Devices (L33789). 

A power seating system - tilt only, recline only, or combination tilt and recline - with or without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met: 

1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices LCD; and 

2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT) or practitioner who has specific training and experience in rehabilitation wheelchair evaluations of the beneficiary's seating and positioning needs. The PT, OT, or practitioner may have no financial relationship with the supplier; and

3. 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. 

4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or 

5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or 

6. The power seating system is needed to manage increased tone or spasticity. 

If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.

You can find this rule at Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). 

The rules also say that up to two batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are allowed if required for a power wheelchair. You can find this rule at Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792).

The rules also say that positioning seat cushion (E2605, E2606), positioning back cushion (E2613, E2614, E2615, E2616, E2620, E2621), and positioning accessory (E0953, E0955, E0956, E0957, E0960) are covered for a beneficiary who meets both of the following criteria:

1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and 

2. The beneficiary has any significant postural asymmetries that are due to one of the following (a or b): 

a. A diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article; or 

b. A diagnosis code listed in Group 3 of the ICD-10 code list in the LCD-related Policy Article. 

You can find this rule at Local Coverage Determination (LCD): Wheelchair Seating (L33312).

The rules also say that a headrest (E0955) is also covered when the beneficiary has a covered manual tilt-in-space, manual semi or fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt and/or recline power seating system. You can find this rule at Local Coverage Determination (LCD): Wheelchair Seating (L33312). 

The rules also say that an example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware (E1028) would be to move the component out of the way so that a beneficiary can perform a slide transfer to a chair or bed. You can find this rule at Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). 

The rules also say that a skin protection seat cushion (E2603, E2604, E2622, E2623) is covered for a beneficiary who meets both of the following criteria:

1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the beneficiary meets Medicare coverage criteria for it; and

2. The beneficiary has either of the following (a or b):

a. Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface as reflected in a diagnosis code listed in Group 1 of the ICD-10 code list in the LCD-related Policy Article; or 

b. Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a functional weight shift as reflected in a diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article.

You can find this rule at Local Coverage Determination (LCD): Wheelchair Seating (L33312). 

The rules also say that adjustable angle footplates coded K0040 (ADJUSTABLE ANGLE FOOTPLATE, EACH) are separately payable when provided with leg rests coded as E1012. You can find this rule at Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504).

The rules also say that an expandable controller is capable of accommodating one or more of the following additional functions:

a. Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.) 

b. Non-proportional input devices (e.g., sip and puff, head array, etc.) 

c. Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power seating actuators though the Control Input Device would require the use of an additional component, E2310 or E2311.)

An expandable controller may also be able to operate one or more of the following:

d. A separate display (i.e., for alternate control devices) 

e. Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control) 

f. An attendant control

You can find this rule at Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504).

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.