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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 commode chair is covered only for enrollees who are confined to a bed or room. The term "room confined" means that the patient's condition is such that leaving the room is medically contraindicated. The accessibility of bathroom facilities generally would not be a factor in this determination. However, confinement of a patient to a home in a case where there are no toilet facilities in the home may be equated to room confinement. You can find this information in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-03, Medical National Coverage Determinations Manual, Chapter 1, Section 280.1. The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are clearly used for medical purposes. Medicare will not pay for: 1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air conditioners, humidifiers, dehumidifiers and electric air cleaners; 2. Equipment used for a patient's comfort or for the convenience of a person caring for the patient. Examples include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. The rules say that Ankle-foot orthoses (AFO) are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle who require stabilization for medical reasons and have the potential to benefit functionally. You can find this information in the Local Coverage Determination (LCD) L33686: Ankle-Foot/Knee-Ankle-Foot Orthosis The rules say that a standard walker (E0130, E0135, E0141, E0143) and related accessories are covered if all of the following criteria (1-3) are met: The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home. The beneficiary is able to safely use the walker; and The functional mobility deficit can be sufficiently resolved with use of a walker. You can find this information in the Local Coverage Determination (LCD) L33791: Walkers
The rules say that canes (E0100, E0105) and crutches (E0110, E0111, E0112, E0113, E0114, E0116) are covered if all of the following criteria are met: The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADL) in the home. The beneficiary is able to safely use the cane or crutch; and, The functional mobility deficit can be sufficiently resolved by use of a cane or crutch. You can find this information in Local Coverage Determination (LCD) L33733: Canes and Crutches 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.