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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 manual wheelchair for use inside the home (E1037, E1038, E1039, E1161, K0001, K0002, 
K0003, K0004, K0005, K0006, K0007, K0008, K0009) 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 beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted 
cane or walker. 
    C. The beneficiarys 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 beneficiarys 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. 
 
 
ADDITIONAL CRITERIA FOR SPECIFIC MANUAL WHEELCHAIRS (E1037, E1038, E1039, E1161, 
K0002, K0003, K0004, K0005, K0006, K0007, K0008) 
 
In addition to the general manual wheelchair criteria above, the specific criteria below must be met for each 
manual wheelchair. If the specific criteria are not met, the manual wheelchair will be denied as not reasonable 
and necessary. 
 
An ultra lightweight manual wheelchair (K0005) is covered for a beneficiary if criteria (1) or (2) is met and (3) 
and (4) are met: 
 
    1. The beneficiary must be a full-time manual wheelchair user. 
    2. The beneficiary must require individualized fitting and adjustments for one or more features such as, but 
not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated 
by a K0001 through K0004 manual wheelchair. 
    3. The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical 
professional (LCMP), such as a PT or OT, or physician 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 LCMP may have no financial relationship 
with the supplier. 
    4. The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) 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 patient. You can find this information in Medicare's 
Local Coverage Determination (LCD): Manual Wheelchair Bases (L33788). 
 
The rules say a nonstandard seat width and/or depth for a manual wheelchair (E2201, E2202, E2203, E2204) is 
covered only if the beneficiary's physical dimensions justify the need. 
 
Elevating legrests (E0990, K0046, K0047, K0053, 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. 
 
    Adjustable arm height option (E0973, K0017, K0018, K0020) is covered if the beneficiary requires an arm 
height that is different from that available using nonadjustable arms and the beneficiary spends at least 2 hours 
per day in the wheelchair. 
 
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 
information in Medicare's Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). 
 
The rules say 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 beneficiarys seating and positioning needs. The PT or OT may have no 
financial relationship with the supplier 
 
You can find this information in Medicare's Local Coverage Determination (LCD): Wheelchair Seating 
(L33312). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.