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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 state that all of the following basic criteria (A-C) must be met for a power mobility device or a push-
rim activated power assist device to be covered. Additional coverage criteria for specific devices are listed 
below. 
 
    The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or 
more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and 
bathing in customary locations in the home. A mobility limitation is one that: 
        Prevents the beneficiary from accomplishing an MRADL entirely, or 
        Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the 
attempts to perform an MRADL; or 
        Prevents the beneficiary from completing an MRADL within a reasonable time frame. 
    The beneficiarys mobility limitation cannot be sufficiently and safely resolved by the use of an 
appropriately fitted cane or walker. 
 
    The beneficiary does not have sufficient upper extremity function to self-propel an optimally-configured 
manual wheelchair in the home to perform MRADLs during a typical day. 
        Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or 
absence of one or both upper extremities are relevant to the assessment of upper extremity function. 
        An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating 
options, and other appropriate nonpowered accessories. 
 
(A POV is covered if all of the basic coverage criteria (A-C) have been met and if criteria D-I are also met. 
 
    The beneficiary is able to: 
        Safely transfer to and from a POV, and 
        Operate the tiller steering system, and 
        Maintain postural stability and position while operating the POV in the home.     The beneficiarys mental capabilities (e.g., cognition, judgment) and physical capabilities (e.g., vision) are 
sufficient for safe mobility using a POV in the home. 
 
    The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the POV that is provided.) 
 
A power wheelchair is covered if: 
 
    All of the basic coverage criteria (A-C) are met; and 
    The beneficiary does not meet coverage criterion D, E, or F for a POV; and 
    Either criterion J or K is met; and 
    Criteria L, M, N, and O are met; and 
    Any coverage criteria pertaining to the specific wheelchair type (see below) are met. 
 
    The beneficiary has the mental and physical capabilities to safely operate the power wheelchair that is 
provided; or 
 
    If the beneficiary is unable to safely operate the power wheelchair, the beneficiary has a caregiver who is 
unable to adequately propel an optimally configured manual wheelchair, but is available, willing, and able to 
safely operate the power wheelchair that is provided; and 
    The beneficiarys weight is less than or equal to the weight capacity of the power wheelchair that is provided 
and greater than or equal to 95% of the weight capacity of the next lower weight class PWC  i.e., a Heavy 
Duty PWC is covered for a beneficiary weighing 285  450 pounds; a Very Heavy Duty PWC is covered for a 
beneficiary weighing 428  600 pounds; an Extra Heavy Duty PWC is covered for a beneficiary weighing 570 
pounds or more. 
    The beneficiarys home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the power wheelchair that is provided. 
    Use of a power wheelchair will significantly improve the beneficiarys ability to participate in MRADLs and 
the beneficiary will use it in the home. For beneficiaries with severe cognitive and/or physical impairments, 
participation in MRADLs may require the assistance of a caregiver. 
 
    The beneficiary has not expressed an unwillingness to use a power wheelchair in the home. 
 
A Group 3 PWC with Multiple Power Options (K0861, K0862, K0863, K0864) is covered if: 
 
    The Group 3 criteria IV(A) and IV(B) are met; 
 
IV(A). All of the coverage criteria (a)-(e) for a PWC are met; and 
IV(B). The beneficiary's mobility limitation is due to a neurological condition, myopathy, or congenital skeletal 
deformity 
and 
 
    The Group 2 Multiple Power Options (criteria III[A] and III[B]) are met. 
 
    Criterion 1 or 2 is met; and 
    Criteria 3 and 4 are met. 
        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. 
        The beneficiary uses a ventilator which is mounted on the wheelchair. 
        The beneficiary has had 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 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. 
        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. 
 
One example (not all-inclusive) of a covered indication for swingaway, retractable, or removable hardware 
(E1028) would be to move the component out of the way so that a beneficiary can perform a slide transfer to a 
chair or bed. 
 
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: 
 
    The beneficiary meets all the coverage criteria for a power wheelchair described in the Power Mobility 
Devices LCD; and 
    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 of the beneficiarys seating and positioning needs. The PT, OT, or 
practitioner may have no financial relationship with the supplier; and 
    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. 
    The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional 
weight shift; or 
    The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently 
transfer from the wheelchair to bed; or 
    The power seating system is needed to manage increased tone or spasticity. 
 
A safety belt/pelvic strap (E0978) is covered if the beneficiary has weak upper body muscles, upper body 
instability or muscle spasticity which requires use of this item for proper positioning. 
 
Swingaway, retractable, or removable hardware (E1028) is non-covered if the primary indication for its use is 
to allow the beneficiary to move close to desks or other surfaces. If it is ordered for this indication, a GY 
modifier must be added to the code. 
 
Code E1028 is used for 
 
        Swingaway hardware used with remote joysticks or touchpads, 
 
        Swingaway or flip-down hardware for head control interfaces E2327, E2328, E2329, E2330, and 
 
        Swingaway hardware for an indicator display box that is related to the multi-motor electronic connection 
codes E2310 or E2311. 
 
Code E1028 is not to be used for swingaway hardware used with a sip and puff interface (E2325) because 
swingaway hardware is included in the allowance for that code. Code E1028 is not to be used for hardware on a 
wheelchair tray (E0950). Do not use E1028 in addition to E1020 (Residual limb support system) as it includes 
swingaway hardware. 
 
A power seat elevation system will be covered if a beneficiary meets the coverage criteria for either a Group 2 single power option or multiple power option power-driven wheelchair, or a Group 3 power-driven wheelchair 
as described in the Power Mobility Devices LCD and meets the coverage criteria for seat elevation equipment 
as described in CMS Medicare National Coverage Determinations (NCD) Manual (Pub. 100-03) Chapter 1, 
Part 4, Section 280.16 Seat Elevation Equipment (Power Operated) on Power Wheelchairs. 
You can find this information in the Local Coverage Determination (LCD): Wheelchair Options/Accessories 
(L33792). 
 
A non-expandable controller has the following features: 
 
    May have the ability to control up to 2 power seating actuators through the drive control (for example, seat 
elevator and single actuator power elevating legrests). (Note: Control of the power seating actuators though the 
Control Input Device would require the use of an additional component, E2310 or E2311.) 
    Can accommodate only an integral joystick or a standard proportional remote joystick 
    May allow for the incorporation of an attendant control 
 
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.) 
 
An expandable controller may also be able to operate one or more of the following: 
 
    A separate display (i.e., for alternate control devices) 
    Other electronic devices (e.g., control of an augmentative speech device or computer through the chair's 
drive control) 
    An attendant control 
 
A harness (E2313) describes all of the wires, fuse boxes, fuses, circuits, switches, etc. that are required for the 
operation of an expandable controller. It also includes all the necessary fasteners, connectors, and mounting 
hardware. Code E2313 is separately billable in addition to an expandable controller both at initial issue and 
with complete replacement of the expandable controller. Code K0108 must not be used for any component or 
feature of an expandable controller at the time of initial issue. The reimbursement for any type of complete 
expandable controller is included in the allowance for codes E2377/E2376 plus E2313. However, if individual 
components of the harness are replaced, code K0108 should be used. 
 
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). 
 
Code E2323 includes prefabricated joystick handles that have shapes other than a straight stick - e.g., U shape 
or T shape - or that have some other nonstandard feature - e.g., flexible shaft. 
 
A sealed battery (E2359, E2361, E2363, E2365, E2371, E2397, K0733) is separately payable from a power wheelchair base. 
 
You can find this information in the Local Coverage Article: Wheelchair Options/Accessories - Policy Article 
(A52504). 
 
A skin protection seat cushion (E2603, E2604, E2622, E2623) is covered for a beneficiary who meets both of 
the following criteria: 
 
    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 
    The beneficiary has either of the following (a or b): 
        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 
        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: 
 
    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 
    The beneficiary has any significant postural asymmetries that are due to one of the following (a or b): 
        A diagnosis code listed in Group 2 of the ICD-10 code list in the LCD-related Policy Article; or 
        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. (Note 
special instructions for a combination skin protection and positioning cushion in the ICD-10 code list in the 
LCD-related Policy Article.) 
 
A headrest (E0955) is also covered when the beneficiary has a covered manual tilt-in-space, manual semi or 
fully reclining back on a manual wheelchair, a manual fully reclining back on a power wheelchair, or power tilt 
and/or recline power seating system. 
 
You can find this information in the Local Coverage Determination (LCD): Wheelchair Seating (L33312). 
 
Effective for services performed on or after May 16, 2023, power seat elevation equipment is reasonable and 
necessary for individuals using complex rehabilitative power-driven wheelchairs (Complex rehabilitative 
power-driven wheelchairs are defined in 42 CFR 414.202), when the following conditions are met: 
 
1. The individual has undergone a specialty evaluation that confirms the individuals ability to safely operate 
the seat elevation equipment in the home. This evaluation must be performed by a licensed/certified medical 
professional such as a physical therapist (PT), occupational therapist (OT), or other practitioner, who has 
specific training and experience in rehabilitation wheelchair evaluations; and, 
2. At least one of the following apply: 
 
    The individual performs weight bearing transfers to/from the power wheelchair while in the home, using 
either their upper extremities during a non-level (uneven) sitting transfer and/or their lower extremities during a 
sit to stand transfer. Transfers may be accomplished with or without caregiver assistance and/or the use of 
assistive equipment (e.g. sliding board, cane, crutch, walker, etc.); or,     The individual requires a non-weight bearing transfer (e.g. a dependent transfer) to/from the power 
wheelchair while in the home. Transfers may be accomplished with or without a floor or mounted lift; or, 
    The individual performs reaching from the power wheelchair to complete one or more mobility related 
activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in customary 
locations within the home. MRADLs may be accomplished with or without caregiver assistance and/or the use 
of assistive equipment. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 280.16. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.