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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 Multiple Power Option PWC (such as code K0842) is covered if all of the basic 
coverage criteria for a power wheelchair (PWC) are met and if:  
A. Criterion 1 or 2 is met; and 
B. Criteria 3 and 4 are met.  
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. 
3. 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. 
4. 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. 
If a Group 2 Multiple Power Option PWC is provided and if criterion (A) or (B) is not met, it will be denied as 
not reasonable and necessary. 
 
If the PWC base is not covered, then related accessories will be denied. You can find this information in the 
Local Coverage Determination (LCD) for 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 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 PT or 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 this information in the Local Coverage Determination (LCD) for 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.