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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 state that a custom fabricated seat cushion (E2609) is covered if criteria (1) and (3) are met. A custom 
fabricated back cushion (E2617) is covered if criteria (2) and (3) are met: 
 
1. Beneficiary meets all of the criteria for a prefabricated skin protection seat cushion or positioning seat 
cushion; 
 
2. Beneficiary meets all of the criteria for a prefabricated positioning back cushion; 
 
3. 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. 
 
A skin protection seat cushion (E2603, E2604, E2622, E2623) 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 (E2605, E2606), positioning back cushion (E2613, E2614, E2615, E2616, E2620, 
E2621), and positioning accessory (E0953, E0955, E0956, E0957, E0960) 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 one of the following (a or b): 
 
a. A diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article; or 
 
b. A diagnosis code listed in Group 3 of the ICD-10 code list in the LCD-related Policy Article. 
 
A combination skin protection and positioning seat cushion (E2607, E2608, E2624, E2625) is covered for a 
beneficiary who meets the criteria for both a skin protection seat cushion and a positioning seat cushion. 
 
You can find this information in the Local Coverage Determination (LCD): Wheelchair Seating (L33312). 
 
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.