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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 medically necessary services are those that are reasonable and necessary for the diagnosis or
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).

The rules say that services that are not medically necessary are not covered. The rules also say that
experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and
411.15(o).

The rules say that 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 in the Local Coverage Article: Wheelchair
Options/Accessories - Policy Article (A52504).

The rules say a power seating system - tilt only, recline only, or combination tilt and recline - with or without
power elevating leg rests 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 described in the Power 
Mobility Devices LCD; and
2. 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 of the beneficiary's 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 Assistive Technology 
Professional (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.

The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are
clearly used for medical purposes. Medicare will not pay for:

1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air
conditioners, humidifiers, dehumidifiers and electric air cleaners;

2. Equipment used for a patient's comfort or for the convenience of a person caring for the 
patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help 
devices such as grab bars. You can find these rules in the Centers for Medicare and Medicaid 
Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1.

If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.

You can find this in the Local Coverage Determination (LCD): Wheelchair Options/Accessories (L33792).

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.