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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 PCDs coded as E0650, E0651, E0652 are used only in the treatment of lymphedema or for
the treatment of chronic venous insufficiency with venous stasis ulcers. Reimbursement for these items is based
upon the criteria in the following sections. PCD coded as E0675 is used in the treatment of peripheral arterial
disease. Claims for E0675 will be denied as not reasonable and necessary as outlined below.

A PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with
chronic and severe lymphedema when all of the following three requirements are met:

The beneficiary has a diagnosis of lymphedema as defined above, and
The beneficiary has persistence of chronic and severe lymphedema as identified by the documented presence
of at least one of the following clinical findings:
Marked hyperkeratosis with hyperplasia and hyperpigmentation,
Papillomatosis cutis lymphostatica,
Deformity of elephantiasis,
Skin breakdown with persisting lymphorrhea,
Detailed measurements over time confirming the persistence of the lymphedema with a history evidencing
a likely etiology, and
In addition to this documented persistence, the lymphedema is then documented to be unresponsive to other
clinical treatment over the course of a required four-week trial. (See below for trial guidelines.)

A PCD coded as E0650 or E0651 used to treat lymphedema that does not meet all of the requirements above is
not eligible for reimbursement. Claims will be denied as not reasonable and necessary.

A PCD coded as E0650 or E0651 used to treat edema from causes other than lymphedema is not eligible for
reimbursement. Claims will be denied as not reasonable and necessary.

A PCD coded as E0652 is not covered for the treatment of lymphedema of the extremities alone even if the criteria in this section are met. Claims will be denied as not reasonable and necessary. Refer below to the sections III - LYMPHEDEMA EXTENDING ONTO THE CHEST, TRUNK AND/OR ABDOMEN and PCD Code Selection for additional information about the limited coverage for PCD coded as E0652. 

PCD coded as E0652 is not covered for the treatment of CVI even if the criteria in this section are met. Claims will be denied as not reasonable and necessary. Refer below to the sections III - LYMPHEDEMA EXTENDING ONTO THE CHEST, TRUNK AND/OR ABDOMEN and PCD Code Selection for additional information about the limited coverage for PCD coded as E0652. 

III - LYMPHEDEMA EXTENDING ONTO THE CHEST, TRUNK AND/OR ABDOMEN 

A segmented, calibrated gradient pneumatic compression device (HCPCS code E0652) is only covered when the individual has unique characteristics which prevent them from receiving adequate satisfactory pneumatic compression treatment using a nonsegmented device along with a segmented appliance or compression device without manual control of the pressure in each chamber. 

A PCD coded as E0652, is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen when all of the following are met: 

The beneficiary has lymphedema of an extremity as defined above 
The coverage criteria for an E0650 or E0651 are met 
The beneficiary has lymphedema extending onto the chest, trunk and/or abdomen that extends past the limits of a standard compression sleeve, and the chest, trunk and/or abdominal lymphedema has failed to improve with a four-week trial. (See below for trial guidelines.) 

A PCD coded as E0652 used to treat lymphedema extending onto the chest, trunk and/or abdomen that does not meet all of the requirements above is not eligible for reimbursement. Claims will be denied as not reasonable and necessary. 

A PCD coded as E0652 used to treat lymphedema not extending onto the chest, trunk and/or abdomen or CVI is not eligible for reimbursement. Claims will be denied as not reasonable and necessary. 

PCD related accessories (E0655, E0656, E0657, E0660, E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673) are eligible for reimbursement only when the appropriate, related base PCDs (E0650, E0651, E0652, E0675) meets the applicable coverage criteria for that type of PCD. If the base PCD is not covered, related accessories are not eligible for reimbursement. Claims for related items will be denied as not reasonable and necessary. 

You can find this information in Medicare's Local Coverage Determination (LCD): Pneumatic Compression Devices (L33829).

If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.