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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 power seating system - tilt only, recline only, or combination tilt and recline - with or without power elevating leg rests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met: The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility Devices LCD; and 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; and 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. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; or The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; or The power seating system is needed to manage increased tone or spasticity. If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792).
The rules say that a positioning seat cushion (E2603) is are covered for a beneficiary who meets specific diagnosis criteria. A headrest (E0955) is also covered when the beneficiary has a covered manual tilt-in-space, manual semi or fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt and/or recline power seating system. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Local Coverage Determination (LCD): Wheelchair Seating (L33312).
The rules say swing away, retractable, or removable hardware (E1028) is non-covered if the primary indication for its use is to allow the beneficiary to move close to desks or other surfaces. If it is ordered for this indication, a GY modifier must be added to the code. You can find this rule in the Centers for Medicare and Medicaid Services, Internal Only Manual, Local Coverage Article: Wheelchair Options/Accessories - Policy Article (A52504). The rules say up to two batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are allowed if required for a power wheelchair. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792).
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