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Decision: unknown

 
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 skin protection seat cushion is 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 either of the following (a or b): 
a. Current pressure ulcer or past history of a pressure ulcer on the area of contact with the seating 
surface as reflected in a diagnosis code listed in Group 1 of the ICD-10 code list in the LCD-
related Policy Article; or 
b. Absent or impaired sensation in the area of contact with the seating surface or inability to carry 
out a functional weight shift as reflected in a diagnosis code listed in Group 2 of the ICD-10 
code list in the LCD-related Policy Article. 
A positioning seat cushion, positioning back cushion, and positioning accessory 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 a diagnosis code listed in 
Group 2 or Group 3 of the ICD-10 cod list in the LCD related Policy Article.  
A custom fabricated seat cushion (E2609) is covered if the beneficiary meets all of the criteria for a 
prefabricated skin protection seat cushion or positioning seat cushion and when 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. 
 
A custom fabricated back cushion (E2617) is covered if the beneficiary meets all of the criteria for a 
prefabricated positioning back cushion and when 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 this information in the Local Coverage Determination (LCD): Wheelchair Seating (L33312). 
 
The rules say that Medicare will pay for durable medical equipment (DME) that is reasonable and necessary for 
treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers 
equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment 
already available to an enrollee. 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(C). 
 
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.