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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 3 power wheelchair (PWC) with Multiple Power Options (K0861, K0862, K0863, 
K0864) is covered if: 
A. All of the coverage criteria for a PWC are met; and 
B. The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal 
deformity) 
C. Criterion 1 or 2 is met; and 
D. Criteria 3 and 4 are met. 
   1. The beneficiary meets coverage criteria for a power tilt and recline seating system 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. 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.) 
You can find this information in the Local Coverage Determination (LCD): Power Mobility Devices (L33789). 
 
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; and 
2. A specialty evaluation that was performed by a licensed/certified medical professional, such as a PT or O) 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 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. 
You can find this information 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.