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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 equipment which the beneficiary owns or is a capped rental item may be replaced in cases 
of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, 
flood). A physicians order and/or new Certificate of Medical Necessity (CMN), when required, is needed to 
reaffirm the medical necessity of the item. Irreparable wear refers to deterioration sustained from day-to-day 
usage over time and a specific event cannot be identified. Replacement of equipment due to irreparable wear 
takes into consideration the reasonable useful lifetime of the equipment. If the item of equipment has been in 
continuous use by the patient on either a rental or purchase basis for the equipments useful lifetime, the 
beneficiary may elect to obtain a new piece of equipment. Replacement may be reimbursed when a new 
physician order and/or new CMN, when required, is needed to reaffirm the medical necessity of the item. The 
reasonable useful lifetime of durable medical equipment is determined through program instructions. In the 
absence of program instructions, the reviewer may determine the reasonable useful lifetime of equipment, but 
in no case can it be less than 5 years. Computation of the useful lifetime is based on when the equipment is 
delivered to the beneficiary, not the age of the equipment. Replacement due to wear is not covered during the 
reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover repair 
up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the 
beneficiary.  
 
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.2. 
 
The rules say that an ultra-lightweight manual wheelchair (K0005) is covered for a beneficiary if criteria (1) or 
(2) is met and (3) and (4) are met: 
 
    1. The beneficiary must be a full-time manual wheelchair user. 
 
    2. The beneficiary must require individualized fitting and adjustments for one or more features such as, but  
    not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be  
    accommodated by a K0001 through K0004 manual wheelchair. 
 
    3. 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 (see Documentation Requirements section). The LCMP may have no financial relationship      with the supplier. 
 
    4. The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) 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 patient. 
 
You can find this information in the 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.