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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 Group 3 power wheelchair (PWC) with Single Power Option (such as code K0856) is 
covered if: 
     A. All of the coverage criteria for a PWC are met; and 
     B. The beneficiarys mobility limitation is due to a neurological condition, myopathy, or congenital 
deformity; and 
     C. The beneficiary has had 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 and that documents the medical necessity for 
the wheelchair and its special features (see Documentation Requirements section). The PT, OT, or practitioner 
may have no financial relationship with the supplier; and 
     D. The wheelchair is provided by a supplier that employs a Rehabilitation Engineering and Assistive 
Technology Society of North America (RESNA) certified Assistive Technology Professional (ATP) who 
specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the 
beneficiary. 
     E. Criterion 1 or 2 is met; and 
          1. The beneficiary meets coverage criteria for a power tilt and recline seating system (see Wheelchair 
Options and Accessories policy) and the system is being used on the wheelchair. 
          2. The beneficiary uses a ventilator which is mounted on the wheelchair. 
 
If the PWC base is not covered, then related accessories will be denied. You can find this information in the 
Local Coverage Determination (LCD) for Power Mobility Devices (L33789). 
 The rules say that a power seating system  tilt only, recline only, or combination tilt and recline  with or 
without power elevating legrests will be covered if criteria 1, 2, and 3 are met and if criterion 4, 5, or 6 is met: 
 
    1. The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility 
Devices LCD; and 
    2. 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 beneficiarys seating and positioning needs. The PT, OT, or 
practitioner may have no financial relationship with the supplier; and 
    3. 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. 
    4. The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional 
weight shift; or 
    5. The beneficiary utilizes intermittent catheterization for bladder management and is unable to 
independently transfer from the wheelchair to bed; or 
    6. 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 information in the Local Coverage Determination (LCD) for Wheelchair Options/Accessories 
(L33792). 
 
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 information in Local Coverage Determination (LCD): Wheelchair 
Options/Accessories (L33792). 
 
A positioning seat cushion (E2605, E2606), positioning back cushion (E2613, E2614, E2615, E2616, E2620, 
E2621), and positioning accessory (E0953, E0955, E0956, E0957, E0960) are covered for a beneficiary who 
meets both of the following criteria: 
 
    1. The beneficiary has a manual wheelchair or a power wheelchair with a sling/solid seat/back and the 
beneficiary meets Medicare coverage criteria for it; and 
 
    2. The beneficiary has any significant postural asymmetries that are due to one of the following (a or b): 
 
        a. A diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article; or 
 
        b. A diagnosis code listed in Group 3 of the ICD-10 code list in the LCD-related Policy Article. 
 
A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) is covered for a 
beneficiary who meets the criteria for both a skin protection seat cushion and a positioning seat cushion. (Note 
special instructions for a combination skin protection and positioning cushion in the ICD-10 code list in the 
LCD-related Policy Article.) 
 
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. 
 
If the beneficiary has a POV or a power wheelchair with a captain's chair seat, a headrest or other positioning 
accessory will be denied as not reasonable and necessary. 
 
If a skin protection seat cushion, positioning seat cushion, or combination skin protection and positioning seat cushion is provided and if the stated coverage criteria are not met, it will be denied as not reasonable and 
necessary. 
 
If a positioning back cushion is provided for a beneficiary who does not meet the stated coverage criteria, it 
will be denied as not reasonable and necessary. You can find this information in Local Coverage Determination 
(LCD): Wheelchair Seating (L33312). 
 
Swingaway, 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. 
Code E1028 is used for 
 
        1. Swingaway hardware used with remote joysticks or touchpads, 
        2. Swingaway or flip-down hardware for head control interfaces E2327, E2328, E2329, E2330, and 
        3. Swingaway hardware for an indicator display box that is related to the multi-motor electronic 
connection codes E2310 or E2311. 
 
Code E1028 is not to be used for swingaway hardware used with a sip and puff interface (E2325) because 
swingaway hardware is included in the allowance for that code. Code E1028 is not to be used for hardware on a 
wheelchair tray (E0950). Do not use E1028 in addition to E1020 (Residual limb support system) as it includes 
swingaway hardware. 
 
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. You 
can find this information in the Local Coverage Article for Wheelchair Options/Accessories - Policy Article 
(A52504). 
 
The rules say that medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 
411.15(o). 
 
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.