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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 power tilt and/or recline seating systems (E1002, E1003, E1004, E1005, E1006, E1007, 
E1008, E1009, E1010, E1012): 
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: 
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 beneficiarys 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.  
You can find this information in the Local Coverage Determination (LCD) - Wheelchair Options/Accessories 
(L33792). 
 
A POV or power wheelchair with Captain's Chair is not appropriate for a beneficiary who needs a separate 
wheelchair eat and/or back cushion. If a skin protection and/or positioning seat or back cushion that meets coverage criteria (see Wheelchair Seating LCD) is provided with a POV or a power wheelchair with Captain's 
Chair, the POV or PWC will be denied as not reasonable and necessary. (Refer to Wheelchair Seating LCD and 
Policy Article for information concerning coverage of general use, skin protection, or positioning cushions 
when they are provided with a POV or power wheelchair with Captain's Chair.) 
 
For beneficiaries who do not have special skin protection or positioning needs, a power wheelchair with 
Captains Chair provides appropriate support. Therefore, if a general use cushion is provided with a power 
wheelchair with a sling/solid seat/back instead of Captains Chair, the wheelchair and the cushion(s) will be 
covered only if either criterion 1 or criterion 2 is met: 
1. The cushion is provided with a covered power wheelchair base that is not available in a Captains Chair 
model  i.e., codes K0839, K0840, K0843, K0860, K0861, K0862, K0863, K0864, K0890, K0891; or. 
2. A skin protection and/or positioning seat or back cushion that meets coverage criteria is provided. 
If one of these criteria is not met, both the power wheelchair with a sling/solid seat and the general use cushion 
will be denied as not reasonable and necessary. You can find this information in the Local Coverage 
Determination (LCD) - Power Mobility Devices (L33789). 
 
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.