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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. 
 
In addition to the general manual wheelchair criteria above, the specific criteria below must be met for each 
manual wheelchair. If the specific criteria are not met, the manual wheelchair will be denied as not reasonable 
and necessary. 
The rules say an ultra-lightweight manual wheelchair (K0005) is covered for a beneficiary if criteria (1) or (2) 
is met and (3) and (4) are met: 
1. The beneficiary must be a full-time manual wheelchair user. 
2. The beneficiary must require individualized fitting and adjustments for one or more features such as, 
but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be 
accommodated by a K0001 through K0004 manual wheelchair. 
3. The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical 
professional (LCMP), such as a PT or OT, or physician 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 LCMP may have no financial 
relationship with the supplier. 
4. The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) 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 patient. 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.3. 
The rules say that replacement refers to the provision of an identical or nearly identical item. Equipment which 
the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. 
Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood).  A physician's order 
and/or new Certificate of Medical Necessity (CMN), when required, is needed to reaffirm the medical necessity 
of the item. Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific 
event cannot be identified.  Replacement of equipment due to irreparable wear takes into consideration the 
reasonable useful lifetime of the equipment. You can find this rule in the Medicare Benefit Policy Manual, 
Chapter 15, Section 100.2. 
 The rules say that the reasonable useful lifetime of durable medical equipment is determined through program 
instructions. In the absence of program instructions, A/B MACs may determine the reasonable useful lifetime 
of equipment, but in no case can it be less than five years. You can find this rule in the Medicare Benefit Policy 
Manual, Chapter 15, Section 100.2. 
 
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.