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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 power seat elevation feature (E2300) and power standing feature (E2301) are non-covered
because they are not primarily medical in nature. If a wheelchair has an electrical connection device described
by code E2310 or E2311 and if the sole function of the connection is for a power seat elevation or power
standing feature, it will be denied as non-covered. Codes E2310 and E2311 describe the electronic components
that allow the beneficiary to control two or more of the following motors from a single interface (e.g.,
proportional joystick, touchpad, or non-proportional interface): power wheelchair drive, power tilt, power
recline, power shear reduction, power leg elevation, power seat elevation, power standing. It includes a
function selection switch which allows the beneficiary to select the motor that is being controlled and an
indicator feature to visually show which function has been selected. When the wheelchair drive function has
been selected, the indicator feature may also show the direction that has been selected (forward, reverse, left,
right). This indicator feature may be in a separate display box or may be integrated into the wheelchair
interface. Payment for the code includes an allowance for fixed mounting hardware for the control box and for
the display box (if present). An expandable controller is capable of accommodating one or more of the
following additional functions: Other types of proportional input devices (e.g., mini-proportional or compact
joysticks, touchpads, chin control, head control, etc.) Non-proportional input devices (e.g., sip and puff, head
array, etc.) Operate 3 or more powered seating actuators through the drive control. (Note: Control of the power
seating actuators though the Control Input Device would require the use of an additional component, E2310 or
E2311.) Code E1028 is used for Swing away hardware used with remote joysticks or touchpads, Swing away
or flip-down hardware for head control interfaces E2327, E2328, E2329, E2330, and Swing away hardware for
an indicator display box that is related to the multi-motor electronic connection codes E2310 or E2311. You
can find these rules in the Local Coverage Article Wheelchair Options/Accessories - Policy Article A52504
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or
carrier sufficient information to determine whether payment is due and the amount of payment. You can find
this rule at 42 CFR 424.5.
The rules say for Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met.
You can see this in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-08,
Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.1.
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.