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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 all of the following basic criteria (A-C) must be met for a power mobility device or a push-
rim activated power assist device to be covered. 
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. 
B. The beneficiarys mobility limitation cannot be sufficiently and safely resolved by the use of an 
appropriately fitted cane or walker. 
C. The beneficiary does not have sufficient upper extremity function to self-propel an optimally configured 
manual wheelchair in the home to perform MRADLs during a typical day. 
 
A Group 3 power wheelchair (PWC) with Single Power Option (K0856, K0857, K0858, K0859, K0860) is 
covered if: 
1. Criteria A and B are met; and 
2. Criteria C and D are met. 
A. All of the coverage criteria for a PWC are met; and 
B. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal 
deformity) 
C. Criterion 1 or 2 is met; and 
B. Criteria 3 and 4 are met. 
   1. 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). 
   2. The beneficiary meets coverage criteria for a power tilt or a power recline seating system and the 
system is being used on the wheelchair. 
   3. 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. 
   4. The wheelchair is provided by a supplier that employs a Rehabilitation Engineering and Assistive 
Technology Society of North America (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 information in the Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
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; and 
2. 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 of the 
beneficiarys 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 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. 
 
Up to two batteries (E2359, E2361, E2363, E2365, E2371, K0733) at any one time are allowed if required for a 
power wheelchair. 
 
An arm trough (E2209) is covered if the beneficiary has quadriplegia, hemiplegia, or uncontrolled arm 
movements. 
 
You can find this information in the Local Coverage Determination (LCD): Wheelchair Options/Accessories 
(L33792). 
 
An expandable controller is capable of accommodating one or more of the following additional functions: 
- Other types of proportional input devices (e.g., mini-proportional or compact joysticks, touchpads, chin 
control, head control, etc.) 
- Non-proportional input devices (e.g., sip and puff, head array, etc.) 
- Operate 3 or more powered seating actuators through the drive control. 
 
An expandable controller may also be able to operate one or more of the following: 
- A separate display (i.e., for alternate control devices) 
- Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's drive 
control) 
- An attendant control 
 
A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting 
hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and 
with complete replacement of the expandable controller. 
 
Codes E2310 and E2311 describe the electronic components that allow the beneficiary to control two or more 
of the following motors from a single interface (e.g., proportional joystick, touchpad, or non-proportional 
interface): power wheelchair drive, power tilt, power recline, power shear reduction, power leg elevation, 
power seat elevation, power standing. It includes a function selection switch which allows the beneficiary to 
select the motor that is being controlled and an indicator feature to visually show which function has been 
selected. When the wheelchair drive function has been selected, the indicator feature may also show the 
direction that has been selected (forward, reverse, left, right). This indicator feature may be in a separate 
display box or may be integrated into the wheelchair interface. Payment for the code includes an allowance for 
fixed mounting hardware for the control box and for the display box (if present). 
 
Code E1028 is used for 
1.  
1. Swingaway hardware used with remote joysticks or touchpads, 
2. Swingaway or flip-down hardware for head control interfaces E2327, E2328, E2329, E2330, and 
3. Swingaway hardware for an indicator display box that is related to the multi-motor electronic 
connection codes E2310 or E2311. 
 
Code E1028 is not to be used for swingaway hardware used with a sip and puff interface (E2325) because 
swingaway hardware is included in the allowance for that code. Code E1028 is not to be used for hardware on a 
wheelchair tray (E0950). Do not use E1028 in addition to E1020 (Residual limb support system) as it includes 
swingaway hardware. 
 
Swingaway, 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. 
 
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 information in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article 
(A52504). 
 
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; 
or 
b. Absent or impaired sensation in the area of contact with the seating surface or inability to carry out a 
functional weight shift. 
 
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 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 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 information in the 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.