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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. 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 beneficiary's 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 rule in the Centers for Medicare and Medicaid Services, 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 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. 

 You can find this rule in the Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD): Wheelchair Seating (L33312).  

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 the Centers for Medicare and Medicaid Services, Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). 

Codes E2310 and E2311 describe electronic components that allow the patient to control two or more of the following motors from a single interface, e.g., proportional joystick, touchpad, or nonproportional interface: 

- Power tilt 
- Power recline, with or without shear reduction 
- Combination power tilt and recline, with or without shear reduction 
- Power leg elevation with or without articulation, power center mount elevating foot platform with or without articulating properties. 

You can find this rule in the Centers for Medicare and Medicaid Services, Local Coverage Article: Power Mobility Devices (A52498).  

A power seat elevation feature (E2300) and power standing feature (E2301) are non-covered because they are not primarily medical in nature. 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 rule in the Centers for Medicare and Medicaid Services, Local Coverage Article: Wheelchair Options/Accessories (A52504).  

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.