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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 the home (K0005) is covered if: 
 
Criteria A, B, C, D, and E are met; and 
Criteria F or G is met: 
 
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, or 
2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the 
attempts to perform an MRADL; or 
3. 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 to 
safely 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 an ultra-lightweight manual wheelchair (K0005) is covered for a beneficiary is criteria 1 or 2 
is met, and 3 and 4 are met: 
 
1. The beneficiary must be a full-time manual wheelchair user. 
2. The beneficiary must require individualized fitting and adjustments for one or more features such as, but not 
limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a 
K0001 through K0004 manual wheelchair. 
3. 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 (see Documentation Requirements section). The LCMP may have no financial relationship 
with the supplier. 
4. 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. 
 
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.