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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 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.  
 
A skin protection seat cushion (E2603, E2604, E2622, E2623) is 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 either of the following (a or b): 
 
          a. Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating surface 
as reflected in a diagnosis code listed in Group 1 of the ICD-10 code list in the LCD-related Policy Article; or 
 
          b. Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a 
functional weight shift as reflected in a diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-
related Policy Article. 
 
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. 
 
You can find this rule in the Local Coverage Determination (LCD) Wheelchair Seating L33312. The rules say that repair or replacement of durable medical equipment (DME), or of a medically necessary 
accessory that is needed for the essential functioning of the DME in relation to the individual's condition, is 
covered and eligible for reimbursement consideration by the Company as follows: 
 
REPAIR 
The repair of a DME item or accessory is covered and eligible for reimbursement consideration when all of the 
following are met: 
 
     a. The DME item itself is covered by Medicare. 
     b. The DME or accessory is provided by a DME supplier. 
     c. The cost to repair, rather than replace, the item is justified based on the useful lifetime of the item. 
     d. The continued use of the DME remains medically necessary. 
 
REPLACEMENT 
The replacement of a previously approved DME item or accessory is covered and eligible for reimbursement 
consideration when all of the following criteria are met: 
     a. The DME item itself is covered by Medicare. 
     b. The replacement DME item or accessory is provided by a DME supplier. 
     c. The continued use of the DME remains medically necessary for the individual. 
     d. The DME replacement is not an additional item (e.g., for use when traveling or for an additional 
residence). 
     e. The replacement is equivalent to a previously approved DME item. 
     f. The replacement accessory is for a DME item previously owned/purchased by or for the individual and 
either one of the following applies: 
          1. There is a change in the individual's condition that requires a replacement (e.g., weight loss or gain, 
growth) 
          2. The DME does not function properly because it has reached or exceeded its life expectancy as 
determined by the manufacturer. 
               a. The Company may determine the reasonable useful lifetime of a specific item based on the 
manufacturer's recommendation or the Food and Drug Administration (FDA)-approved labeling. 
In the absence of the manufacturer's recommendations or FDA labeling, the Company may 
determine the reasonable useful lifetime of a specific item, but in no case can it be less than 5 
years. Replacement due to wear is not covered during the reasonable useful lifetime of the 
equipment; however, the Company will cover repair up to the cost of replacement for medically 
necessary equipment owned by the individual. 
 
Requests for technological advancements or newly released upgrades to equipment, when the original 
equipment still functions properly and/or there are no significant changes in the individual's condition, are 
considered not medically necessary and, therefore, not covered. You can find these rules in the Repair and 
Replacement of Durable Medical Equipment (DME) and Prosthetic Devices Policy #: MA05.062h. 
 
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.