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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. 
 
If a Group 3 Single Power Option or Multiple Power Options PWC is provided and if criterion V(A) or (V)(B) 
is not met, it will be denied as not reasonable and necessary. 
V. A Group 3 PWC with Single Power Option (K0856) is covered if: 
I. The Group 3 criteria IV(A) and IV(B) are met; and 
II. The Group 2 Single Power Option (criteria II[A] and II[B]) or Multiple Power Options 
(criteria III[A] and III[B]) (respectively) are met. 
IV.  Group 3 PWC with no power options is covered if: 
A. All of the coverage criteria (a)-(e) for a PWC are met; and 
B. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital 
skeletal deformity; and 
If a Group 3 PWC is provided and if criteria (IV)(A)  (IV)(D) are not met, it will be denied as not reasonable 
and necessary. 
 
II. A Group 2 Single Power Option PWC (K0835, K0836, K0837, K0838, K0839, K0840) is covered if all 
of the coverage criteria (a)-(e) for a PWC are met and if: 
A. Criterion 1 or 2 is met; and 
B. Criteria 3 and 4 are met. 
I. The beneficiary requires a drive control interface other than a hand or chin-operated 
standard proportional joystick (examples include but are not limited to head control, sip 
and puff, switch control). 
II. The beneficiary meets coverage criteria for a power tilt or a power recline seating system 
(see Wheelchair Options and Accessories policy for coverage criteria) and the system is 
being used on the wheelchair. 
III. 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. 
IV. 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. 
III. A Group 2 Multiple Power Option PWC (K0841, K0842, K0843) is covered if all of the coverage 
criteria (a)-(e) for a PWC are met and if: 
A. Criterion 1 or 2 is met; and 
B. Criteria 3 and 4 are met. 
I. 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. 
II. The beneficiary uses a ventilator which is mounted on the wheelchair. 
III. The beneficiary has had a specialty evaluation that was performed by a licensed/certified 
medical professional, such as a PT or 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. 
IV. 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. 
You can find this rule in the Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
The rules say 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 rule in the Centers for Medicare and Medicaid Services, 
Internet Only Manual, Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792). 
 
The rules say swing away, 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. You can find this rule in the Centers for Medicare and Medicaid 
Services, Internal Only Manual, Local Coverage Article: Wheelchair Options/Accessories - Policy Article 
(A52504). 
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, 
Internet Only Manual, Local Coverage Determination (LCD): Wheelchair Seating (L33312). 
 
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. You 
can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Local Coverage 
Determination (LCD): Wheelchair Seating (L33312). 
 
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.