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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 Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for
a person who meets the following criteria:
1. The person must have a personal mobility deficit;
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such
as toileting, feeding, grooming and bathing in customary locations within the home;
3. The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and
4. The person must be capable of safely operating the PMD.
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B).
A power tilt and recline seating system (E1006-E1008) includes: a solid seat platform and a solid
back; any frame width and depth; detachable or flip-up fixed height or adjustable height armrests; fixed or
swing away detachable leg rests; fixed or flip-up footplates; two motors and related electronics with or without
variable speed programmability; a switch control which is independent of the power wheelchair drive control
interface.
A power leg elevation feature (E1010, E1012) involves dedicated motor(s) and related electronics with or
without variable speed programmability which allows the leg rest to be raised and lowered independently of the
recline and/or tilt of the seating system. It includes a switch control which may or may not be integrated with
the power tilt and/or recline control(s).
Expandable Controller - An electronic system that is capable of accommodating one or more of
the following additional functions:
a. Proportional input devices (e.g., mini, compact, or short throw joysticks, touchpads, chin control, head
control, etc.) other than a standard proportional joystick.
b. Non-proportional input devices (e.g., sip and puff, head array, etc.)
c. 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.)
A 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. If an attendant control (E2331) is provided in addition to a beneficiary-operated
drive control system, it will be denied as non-covered. You can find this information in the Local Coverage
Article: Wheelchair Options/Accessories - Policy Article (A52504).
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.