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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 general use seat cushion (E2601, E2602) and a general use wheelchair back cushion 
(E2611, E2612) are covered for a beneficiary who has a manual wheelchair or a power wheelchair with a 
sling/solid seat/back which meets Medicare coverage criteria. If the beneficiary does not have a covered 
wheelchair, then the cushion will be denied as not reasonable and necessary. If the beneficiary has a power 
operated vehicle (POV) or a power wheelchair with a captain's chair seat, the cushion will be denied as not 
reasonable and necessary. 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 specified conditions 
 
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 
custom fabricated seat cushion (E2609) is covered if criteria (1) and (3) are met. A custom fabricated back 
cushion (E2617) is covered if criteria (2) and (3) are met: 
1. Beneficiary meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat 
cushion; 
2. Beneficiary meets all of the criteria for a prefabricated positioning back cushion; 
3. There is a comprehensive written evaluation by a licensed/certified medical professional, such as a 
physical therapist (PT) or occupational therapist (OT), which clearly explains why a prefabricated 
seating system is not sufficient to meet the beneficiarys seating and positioning needs. The PT or OT 
may have no financial relationship with the supplier. 
 
If a custom fabricated cushion is provided for a beneficiary who does not meet the stated coverage criteria, it 
will be denied as not reasonable and necessary. You can find these rules in Local Coverage Determination 
(LCD) Wheelchair Seating (L33312). 
 The rules state that a manual wheelchair with tilt in space (E1161) is covered if the beneficiary meets the 
general coverage criteria for a manual wheelchair, and if criteria (1) and (2) are met: 
1. The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical 
professional (LCMP), such as a PT or OT, or physician who has specific training and experience in 
rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and 
its special features. The LCMP may have no financial relationship with the supplier. 
2. The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a 
Rehabilitation Engineering 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 patient. 
 
If the manual wheelchair base is not covered, then related accessories will be denied as not reasonable and 
necessary. You can find these rules in Local Coverage Determination (LCD) Manual Wheelchair Bases 
(L33788). 
 
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.