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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 say that a manual wheelchair for use inside of the home is covered if:Criteria A, B, C, D, and E are met; andCriterion F or G ismet.A. 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) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:1. Prevents the beneficiary from accomplishing an MRADL entirely, or2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or3. Prevents the beneficiary from completing an MRADL within a reasonable time frame.B. The beneficiary's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.C. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.D. Use of a manual wheelchair will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home.E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home.F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed tosafely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair.You can find this rule in Local Coverage Determination (LCD):Manual Wheelchair Bases (L33788) -Effective January 1, 2020.The rules say that manual wheelchair for use inside the home (E1161) is covered if:The rules say that custom-fabricated seat cushion or back cushion is covered if the following criteria are met:1. Beneficiary meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion;2. Beneficiary meets all of the criteria for a prefabricated positioning back cushion;3. There is a comprehensive written evaluation by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), which clearly explains why a prefabricated seating system is not sufficient to meet the beneficiary's seating and positioning needs. The PT or OT may have no financial relationship with the supplier.You can find this rule in Local Coverage Determination (LCD):Wheelchair Seating (L33312) -Effective January 1, 2020.The rules say that a skin protection seat cushion 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; and2. 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; orb. 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 covered diagnosis codeYou can find this rule in Local Coverage Determination (LCD):Wheelchair Seating (L33312) -Effective January 1, 2020.The rules say that a positioning seat cushion or back cushion 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; and2. The beneficiary has any significant postural asymmetriesYou can find this rule in Local Coverage Determination (LCD): Wheelchair Seating (L33312) -Effective January 1, 2020.The rules say that a manual wheelchair with tilt-in space is coveredif the beneficiary meets the general coverage criteria for the manual wheelchair above, and if criteria below are met:1. The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features.  The LCMP may have no financial relationship with the supplier.2.The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) 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 patient.You can find this rule in Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788) -Effective January 1, 2020.The rules say that one example (not all-inclusive) of a covered indication for swing-away, 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 in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792) -Effective January 1, 2020.The rules say that elevating legrests (E0990) are covered if:1. The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90-degreeflexion at the knee; or2. The beneficiary has significant edema of the lower extremities that requires an elevating legrest; or3. The beneficiary meets the criteria for and has a reclining back on the wheelchair.You can find this rule in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792) -Effective January 1, 2020.The rules say that a flat free insert (E2213) is a removable ring of firm material that is placed inside of a pneumatic tire to allow the wheelchair to continue to move if the pneumatic tire is punctured. This code may not be used for a foam filled tire. You can find this rule in Local Coverage Article: Wheelchair Options/Accessories -Policy Article (A52504) -Effective January 1, 2020.The rules say that the adjustable arm height option (E0973) is covered if the beneficiary requires an arm height that is different from that available using nonadjustable arms and the beneficiary spends at least 2 hours per day in the wheelchair. You can find this rule in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792) -Effective January 1, 2020.If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.The Plan contract says that the Plancovers items and services in accordance with Medicare rules.