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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 COVERAGE CRITERIA 
 
A manual wheelchair for use inside the home (E1037, E1038, E1039, E1161, K0001, K0002, K0003, K0004, 
K0005, K0006, K0007, K0008, K0009) is covered if criteria A, B, C, D, and E are met; and criterion F or G is 
met. 
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. A mobility limitation is one that: 
1. Prevents the beneficiary from accomplishing an MRADL entirely, or 
2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality 
secondary to the attempts to perform an MRADL; or 
3. Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
B. The beneficiarys mobility limitation cannot be sufficiently resolved by the use of an appropriately 
fitted cane or walker. 
C. The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces 
for use of the manual wheelchair that is provided. 
D. Use of a manual wheelchair will significantly improve the beneficiarys ability to participate in MRADLs 
and the beneficiary will use it on a regular basis in the home. 
E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in 
the home. 
F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities 
needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. 
Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity 
or absence of one or both upper extremities are relevant to the assessment of upper extremity 
function. 
G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the 
wheelchair. 
 
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 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.