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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 at42 Code of Federal Regulations (CFR) Section 422.101.The rules say that a group four wheelchair has added capabilities that are not needed for use in the home. Therefore, if these wheelchairs are provided, they will be denied as not reasonable and necessary. You can find this rule in Local Coverage Determination (LCD): Power Mobility Devices (L33789) -Effective January 1, 2020.The rules say that the power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. If a wheelchair has an electrical connection device described by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power standing feature, it will be denied as non-covered. You can find this rule in Local Coverage Article: Wheelchair Options/Accessories -Policy Article (A52504) -Effective January 1, 2018.The rules say that an expandable controller is capable of accommodating one or more of the following additional functions:-Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin control, head control, etc.)-Non-proportional input devices (e.g., sip and puff, head array, etc.)-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:-A separate display (i.e., for alternate control devices)-Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive control)-An attendant controlYou can find this rule in Local Coverage Article: Wheelchair Options/Accessories -Policy Article (A52504) -Effective January 1, 2020.The rules say that a power seating system (E1007, E1012) is covered if criteria 1, 2, and 3 are met, and if criterion 4, 5, or 6 are met:1. The beneficiary meets all the coverage criteria for a power wheelchair2. 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; and3. 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; or5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or6. The power seating system is needed to manage increased tone or spasticity.You can find this rule in Local Coverage Determination (LCD):Wheelchair Options/Accessories (L33792) -Effective January 1, 2020.The rules say that a positioning back cushion (E2620) and positioningaccessory (E0953, E0955, E0956, E0957, E0960) 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 coveragecriteria for it; and2. The beneficiary has a significant postural asymmetryYou can find this rule in Local Coverage Determination (LCD): Wheelchair Seating (L33312) -Effective January 1, 2020.The rules say that a custom-fabricated back cushion (E2617) is covered if:-The beneficiary meets all of the criteria for a prefabricated positioning back cushion;-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 combination skin protection and positioning seat cushion (E2624) is covered for a beneficiary who meets the criteria for both a skin protection seat cushion and a positioning seat cushion. 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 surfaceb. Absent or impaired sensation in the area of contactwith the seating surface or inability to carry out a functional weight shift as reflected in a diagnosis codeYou can find this rule in Local Coverage Determination (LCD): Wheelchair Seating (L33312) -Effective January 1, 2020.The rules say that one 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 in LocalCoverage 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.