Appeal type: unknown
Decision: unknown

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 medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o). 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. A 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. A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) is covered for a beneficiary who meets the criteria for both a skin protection seat cushion and a positioning seat cushion. (Note special instructions for a combination skin protection and positioning cushion in the ICD-10 code list in the LCD-related Policy Article.) If a skin protection seat cushion, positioning seat cushion, or combination skin protection and positioning seat cushion is provided and if the stated coverage criteria are not met, it will be denied as not reasonable and necessary. If a positioning back cushion is provided for a beneficiary who does not meet the stated coverage criteria, it will be denied as not reasonable and necessary. You can find this in the Local Coverage Determination (LCD): Wheelchair Seating (L33312).
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.