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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; and 
Criterion F or G is 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. 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 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. 

The rules say that one example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware (E1028) would be to move the component out of the way so that a beneficiary can perform a slide transfer to a chair or bed. You can find this rule in Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792) - Effective January 1, 2020. 

The rules say that a custom-fabricated seat cushion (E2609) is covered if criteria 1 and 3 are met. A custom fabricated back cushion (E2617) is covered if criteria (2) and (3) are met: 

1. Beneficiary meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat cushion; 

2. Beneficiary meets all of the criteria for a prefabricated positioning back cushion; 

3. There is a comprehensive written evaluation by a licensed/certified medical professional, such as a physical therapist (PT) or occupational therapist (OT), which clearly explains why a prefabricated seating system is not sufficient to meet the beneficiary's seating and positioning needs. The PT or OT may have no financial relationship with the supplier. 

You can find this rule in Local Coverage Determination (LCD): Wheelchair Seating (L33312) - 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.