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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 manual wheelchair for use inside of the home is covered if:

Criteria A, B, C, D, and E are met; andCriterion F or G ismet.

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. A mobility limitation is one that:

1. Prevents the beneficiary from accomplishing an MRADL entirely, or
2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
3. Prevents the beneficiary from completing an MRADL within a reasonable time frame.

B. The beneficiary's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
C. The beneficiary's home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.
D. Use of a manual wheelchair will significantly improve the beneficiary's ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home.
E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home.
F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair.

You can find this rule in Local Coverage Determination (LCD):Manual Wheelchair Bases (L33788) -Effective January 1, 2020.

The rules say that elevating legrests (K0195) are covered if:

1. The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90 degree flexion at the knee; or
2. The beneficiary has significant edema of the lower extremities that requires an elevating legrest; or . 

3 The beneficiary meets the criteria for and has a reclining back on the wheelchair.You can find this rule in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792) -Effective January 1, 2020.

The rules say that a general use seat cushion (E2601) is covered for a beneficiary who has a manual wheelchair or a power wheelchair with a sling/solid seat/back which meets Medicare coverage criteria. If the beneficiary does not have a covered wheelchair, then the cushion will be denied as not reasonable and necessary. If the beneficiary has a POV or a power wheelchair with a captain's chair seat, the cushion will be denied as not reasonable and necessary. You can find this rule in Local Coverage Determination (LCD): Wheelchair Seating (L33312) -Effective January 1, 2020.

The rules say that a safety belt/pelvic strap (E0978) is covered if the beneficiary has weak upper body muscles, upper body instability or muscle spasticity which requires use of this item for proper positioning. You can find this rule in Local Coverage 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 Plan covers items and services in accordance with Medicare rules.