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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 a Group 2 power wheelchair with multiple power options is covered if: 
A. All of the coverage criteria for a PWC are met; and 
B. 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; and 
C. 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. 
1. The beneficiary meets coverage criteria for a power tilt and recline seating system (see 
Wheelchair Options/Accessories policy) and the system is being used on the wheelchair. 
2. The beneficiary uses a ventilator which is mounted on the wheelchair. 
If a Group 2 Multiple Power Option PWC is provided and if criterion III(A) or III(B) is not met, it will be 
denied as not reasonable and necessary. You can find this information in Local Coverage Determination 
(LCD): Power Mobility Devices (L33789). 
The rules say that 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 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 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 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. 
 
If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary. 
You can find these rules in Local Coverage Determination (LCD) Wheelchair Options/Accessories (L33792). 
 
The rules say that effective for services performed on or after May 16, 2023, power seat elevation equipment is 
reasonable and necessary for individuals using complex rehabilitative power-driven wheelchairs, when the 
following conditions are met: 
1. The individual has undergone a specialty evaluation that confirms the individuals ability to safely 
operate the seat elevation equipment in the home. This evaluation must be performed by a 
licensed/certified medical professional such as a physical therapist (PT), occupational therapist (OT), or 
other practitioner, who has specific training and experience in rehabilitation wheelchair evaluations; 
and, 
2. At least one of the following apply: 
a. The individual performs weight bearing transfers to/from the power wheelchair while in the home, 
using either their upper extremities during a non-level (uneven) sitting transfer and/or their lower extremities during a sit to stand transfer. Transfers may be accomplished with or without caregiver 
assistance and/or the use of assistive equipment (e.g. sliding board, cane, crutch, walker, etc.); or, 
b. The individual requires a non-weight bearing transfer (e.g. a dependent transfer) to/from the power 
wheelchair while in the home. Transfers may be accomplished with or without a floor or mounted 
lift; or, 
c. The individual performs reaching from the power wheelchair to complete one or more mobility 
related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and 
bathing in customary locations within the home. MRADLs may be accomplished with or without 
caregiver assistance and/or the use of assistive equipment. 
You can find this information in National Coverage Determination (NCD): Seat Elevation Equipment (Power 
Operated) on Power Wheelchairs (280.16). 
 
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.