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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. 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.? "Per Medicare references listed below the rules state: ?Section 
424.57(c)(12) requires suppliers, as part of their standards to be met for enrollment and participation, to 
maintain proof of delivery documentation in their files. In certain instances, compliance with proof of delivery 
may be required as a condition of payment, and must be available to the DME MAC, RAC, SMRC, CERT, and 
ZPIC/UPIC on request. For such items, if the supplier does not have appropriate proof of delivery 
documentation within the prescribed timeframes, associated claims will be denied and overpayments recouped. 
We note that non-compliance with supplier standards may also result in revocation from the Medicare program. 
Suppliers who consistently do not provide documentation to support their services may be referred to the OIG 
or NSC for investigation and/or imposition of sanctions. If the beneficiary is newly eligible to the Medicare 
program, the proof of delivery standards require the supplier to obtain a statement, signed and dated by the 
beneficiary (or beneficiary's designee), that the supplier has examined the item."" Also, ?Any person who can 
sign and accept the delivery of durable medical equipment on behalf of the beneficiary.? Suppliers, their 
employees, or anyone else having a financial interest in the delivery of the item are prohibited from signing and 
accepting an item on behalf of a beneficiary (i.e., acting as a designee on behalf of the beneficiary). The 
signature of the designee should be legible. If the signature of the designee is not legible, the supplier/shipping 
service should note the name of the designee on the delivery slip. Three methods of delivery are: Supplier 
delivering directly to the beneficiary or designee; Supplier utilizing a delivery/shipping service to deliver items; 
and Delivery of items to a nursing facility on behalf of the beneficiary. ?The date of delivery may be entered by 
the beneficiary, designee or the supplier. As a general Medicare rule, the date of service shall be the date of 
delivery. Exceptions are made for suppliers who use a delivery/shipping service. If the supplier uses a 
delivery/shipping service, the supplier may use the shipping date as the date of service on the claim. The 
shipping date may be defined as the date the delivery/shipping service label is created or the date the item is 
retrieved for delivery; however, such dates should not demonstrate significant variation. (See Pub. 100-08, 
chapter 5, section 5.2.4 for further information on written orders prior to delivery.)?. 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 and Medicare Program Integrity Manual Chapter 4 - Program Integrity, Section 4.26 - 
Supplier Proof of Delivery Documentation Requirements, Subsection 4.26.1 - Proof of Delivery and Delivery 
Methods. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.