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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 state that a positioning back cushion (E2613, E2614, E2615, E2616, E2620, E2621) is a prefabricated 
cushion which has the following characteristics: 
 
1. For codes E2613, E2614, E2615, E2616, there is at least 25 mm of posterior contour in the pre-loaded state. 
A posterior contour is a backward curve measured from a horizontal line in the midline of the cushion; and 
 
2. For posterior-lateral cushions (E2615, E2616) and for planar cushions with lateral supports (E2620, E2621), 
there is at least 75 mm of lateral contour in the pre-loaded state. A lateral contour is a backward curve 
measured from a horizontal line connecting the lateral extensions of the cushion; and 
 
3. For posterior pelvic cushions (E2613, E2614), there is mounting hardware that is adjustable for horizontal 
position, depth, and angle; and 
 
4. It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and 
 
5. The cushion and cover meet the minimum standards of the California Bulletin 117, California Bulletin 133, 
or equivalent (such as standards established by the ASTM, the EPA, or other national or international standards 
agencies), for flame resistance; and 
 
6. It has a permanent label indicating the model and the manufacturer; and 
 
7. It has a warranty that provides for repair or full replacement if manufacturing defects are identified or the 
surface does not remain intact due to normal wear within 18 months. 
 
The rules also say that a nonadjustable skin protection and positioning seat cushion (E2607, E2608) is a 
prefabricated cushion which has the following characteristics:  
1. It has the minimum structural features described in (a) or (b): 
 
a. The feature must be at least 25 mm in height in the pre-loaded state. It has two or more of the following: 
i. A pre-ischial bar or ridge which is placed anterior to the ischial tuberosities and prevents forward 
migration of the pelvis, 
ii. Two lateral pelvic supports which are placed posterior to the trochanters and are intended to 
maintain the pelvis in a centered position in the seat and/or provide lateral stability to the pelvis, 
iii. A medial thigh support which is placed in contact with the adductor region of the thigh and provides 
the prescribed amount of abduction and prevents adduction of the thighs, 
iv. Two lateral thigh supports which are placed anterior to the trochanters and provide lateral stability 
to the lower extremities and prevent unwanted abduction of the thighs. 
 
b. It has two or more air compartments located in areas which address postural asymmetries, each of which 
must have a cell height of at least 50 mm, must allow the user to add or remove air, and must have a valve 
which retains the desired air volume; and 
 
2. It has the following minimum performance characteristics: 
 
a. Simulation tests demonstrate a loaded contour depth of at least 40mm with an overload deflection of at least 
5 mm, or 
b. Human subject tests demonstrate an average peak pressure index that is less than 85% of that of a standard 
reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and 
 
3. Following testing simulating 18 months of use: 
 
a. Simulation tests demonstrate an overload deflection of at least 5 mm, or 
b. Human subject tests demonstrate an average peak pressure index that is less than 85% of those of a standard 
reference cushion within the area of the ischial tuberosities and sacrum/coccyx; and 
 
4. It has a removable vapor permeable or waterproof cover or it has a waterproof surface; and 
 
5. The cushion and cover meet the minimum standards of the California Bulletin 117, California Bulletin 133, 
or equivalent (such as standards established by the ASTM, the EPA, or other national or international standards 
agencies), for flame resistance; and 
 
6. It has a permanent label indicating the model and the manufacturer; and 
 
7. It has a warranty that provides for repair or full replacement if manufacturing defects are identified or the 
surface does not remain intact due to normal wear within 18 months. 
 
You can find these rules in the Local Coverage Article for Wheelchair Seating - Policy Article, A52505. 
 
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.