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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 state that a power wheelchair is covered if: A. All the basic coverage criteria (A-C) are 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 b. The beneficiary's mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker. c. The beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured manual wheelchair in the home to perform MRADLs during a typical day. B. The beneficiary does not meet coverage criterion D, E, or F for a POV; d. The beneficiary is able to: Safely transfer to and from a POV, and Operate the tiller steering system, and Maintain postural stability and position while operating the POV in the home. e. The beneficiary's mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) sufficient for safe mobility using a POV in the home. f. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the POV that is provided C. Either criterion J or K is met; j. The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is provided; or k. If the beneficiary is unable to safely operate the power wheelchair, the beneficiary has a caregiver who is unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to safely operate the power wheelchair that is provided D. Criteria L, M, N, and O are met; l. The beneficiary's weight is less than or equal to the weight capacity of the power wheelchair that is provided and greater than or equal to 95% of the weight capacity of the next lower weight class PWC - i.e., a Heavy Duty PWC is covered for a beneficiary weighing 285 - 450 pounds; a Very Heavy Duty PWC is covered for a beneficiary weighing 428 - 600 pounds; an Extra Heavy Duty PWC is covered for a beneficiary weighing 570 pounds or more. m. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for the operation of the power wheelchair that is provided.
n. Use of a power wheelchair will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it in the home. For beneficiaries with severe cognitive and/or physical impairments, participation in MRADLs may require the assistance of a caregiver. o. The beneficiary has not expressed an unwillingness to use a power wheelchair in the home. E. Any coverage criteria pertaining to the specific wheelchair type (see below) are met. Group 2 PWC (K0820, K0821, K0822, K0823, K0824, K0825, K0826, K0827, K0828, K0829) is covered if all of the coverage criteria (a)-(e) for a PWC are met and the wheelchair is appropriate for the beneficiary's weight. A power wheelchair, group 2 standard, captains chair (K0823), has a patient weight capacity up to and including 300 pounds. You can find this information in Local Coverage Determination (LCD): Power Mobility Devices (L33789).
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.