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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.
Medicare guidance says "For any DMEPOS item to be covered by Medicare, the patient's medical record must
contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type
and quantity of items ordered and for the frequency of use or replacement (if applicable). The information
should include the patient's diagnosis and other pertinent information including, but not limited to, duration of
the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional
limitations, other therapeutic interventions and results, past experience with related items, etc. If an item
requires a CMN or DIF, it is recommended that a copy of the completed CMN or DIF be kept in the patient's
record Per Medicare references listed below the rules state: "For any DMEPOS item to be covered by
Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition
to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or
replacement (if applicable). The information should include the patient's diagnosis and other pertinent
information including, but not limited to, duration of the patient's condition, clinical course (worsening or
improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and
results, past experience with related items, etc. If an item requires a CMN or DIF, it is recommended that a
copy of the completed CMN or DIF be kept in the patient's record. However, neither a physician's order nor a
CMN nor a DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient
documentation of medical necessity, even though it is signed by the treating physician or supplier. There must
be information in the patient's medical record that supports the medical necessity for the item and substantiates
the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement
or physician attestation (if applicable)". Also, "Before submitting a claim to the DME MAC the supplier must
have on file a dispensing order, the detailed written order, the CMN (if applicable), the DIF (if applicable),
information from the treating physician concerning the patient's diagnosis, and any information required for the
use of specific modifiers or attestation statements as defined in certain DME MAC policies. The supplier
should also obtain as much documentation from the patient's medical record as they determine they need to
assure themselves that coverage criteria for an item have been met. If the information in the patient's medical
record does not adequately support the medical necessity for the item, the supplier is liable for the dollar
amount involved unless a properly executed ABN of possible denial has been obtained." Lastly, "Unless
otherwise specified, the MAC, RAC and ZPIC/UPIC shall request information from the billing
provider/supplier. The treating physician, another clinician, provider, or supplier should submit the requested
documentation. However, because the provider selected for review is the one whose payment is at risk, it is this
provider who is ultimately responsible for submitting, within the established timelines, the documentation
requested by the MAC, CERT, RAC and ZPIC/UPIC.". However, neither a physician's order nor a CMN nor a
DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of
medical necessity, even though it is signed by the treating physician or supplier. There must be information in
the patient's medical record that supports the medical necessity for the item and substantiates the answers on
the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement or physician
attestation (if applicable)". Also," Before submitting a claim to the DME MAC the supplier must have on file a
dispensing order, the detailed written order, the CMN (if applicable), the DIF (if applicable), information from
the treating physician concerning the patient's diagnosis, and any information required for the use of specific
modifiers or attestation statements as defined in certain DME MAC policies. The supplier should also obtain as
much documentation from the patient's medical record as they determine they need to assure themselves that
coverage criteria for an item have been met. If the information in the patient's medical record does not
adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved
unless a properly executed ABN of possible denial has been obtained.". You can find this guidance in the
Medicare Program Integrity Manual, Chapter 5 - Items and Services Having Special DME Review
Considerations, Section 5.7 - Documentation in the Patient's Medical Record and Section 5.8 - Supplier
Documentation; Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking
Corrective Actions, Section 3.2.3.3 - Third-Party Additional Documentation Request.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.