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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 Medicare will cover a Power Mobility Device (PMD) (i.e., power wheelchair or scooter) for
a person who meets the following criteria:
1. The person must have a personal mobility deficit;
2. The deficit must impair their participation in mobility related activities of daily living (MRADLs) such
as toileting, feeding, grooming and bathing in customary locations within the home;
3. The person's condition must not be able to be ameliorated by a walker, cane or manual wheelchair; and
4. The person must be capable of safely operating the PMD.
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication
100-03, Medicare National Coverage Determinations Manual, Section 280.3(B).
The rules say that elevating leg rests are covered if:
1. The beneficiary has a musculoskeletal condition or the presence of a cast or brace which prevents 90-
degree flexion at the knee; or
2. The beneficiary has significant edema of the lower extremities that requires an elevating leg rest; or
3. The beneficiary meets the criteria for and has a reclining back on the wheelchair.
POWER TILT AND/OR RECLINE SEATING SYSTEMS (E1012):
A power seating system - tilt only, recline only, or combination tilt and recline - with or without power
elevating leg rests 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 described in the Power Mobility
Devices LCD; and
2. 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 beneficiary's 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 Assistive Technology
Professional (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.
If these criteria are not met, the power seating component(s) will be denied as not reasonable and necessary.
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.
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.
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.
An option/accessory that is beneficial primarily in allowing the beneficiary to perform leisure or recreational
activities is non-covered. If an option or accessory that is included in another code is billed separately, the
claim line will be denied as not separately payable.
A Column II code is included in the allowance for the corresponding Column I code when provided at the same
time. When multiple codes are listed in column I, all the codes in column II relate to each code in column I.
You can find these rules in the Local Coverage Determination and Article for Wheelchair Options/Accessories
L33792 and A52504 (eff 01/01/20).
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.