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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 if you utilize a shipping service or mail order, the POD documentation must be a complete record 
tracking the item(s) from you to the beneficiary. An example of acceptable proof of delivery would include 
both your detailed shipping invoice and the delivery services tracking information. Your record must be linked 
to the delivery service record by some clear method like the delivery services package identification number 
or your invoice number for the package sent to the beneficiary.  
 
The supplier should also have on file any documentation containing a description of the item delivered to the 
beneficiary to determine the accuracy of claims coding including, but not limited to, a voucher, invoice or 
statement in the supplier records. A description of the items(s) delivered must be noted on the POD. The 
description can be either a narrative description (e.g., lightweight wheelchair base), a HCPCS code, the long 
description of a HCPCS code, or a brand name/model number. 
You can find this information in Local Coverage Article: Standard Documentation Requirements for All 
Claims Submitted to DME MACs (A55426). 
 
The rules say that Medicare will pay for durable medical equipment (DME) that is reasonable and necessary for 
treatment of an illness or injury, or to improve the functioning of a malformed body part. Medicare considers 
equipment to be reasonable and necessary if the equipment does not serve the same purpose as other equipment 
already available to an enrollee. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, 
Section 110.1(C). 
 
The rules say that the reasonable useful lifetime (RUL) of durable medical equipment is determined through 
program instructions. In the absence of program instructions, carriers may determine the reasonable useful 
lifetime of equipment, but in no case can it be less than 5 years. Computation of the useful lifetime is based on 
when the equipment is delivered to the beneficiary, not the age of the equipment. Replacement due to wear is 
not covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, 
Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary 
equipment owned by the beneficiary. Cases suggesting malicious damage, culpable neglect, or wrongful 
disposition of equipment should be investigated and denied where the DME MACs determines that it is 
unreasonable to make program payment under the circumstances. The rules can be found in the Medicare 
Benefit Policy Manual Chapter 15 under Covered Medical and Other Services? Section 110.2. for Repairs, 
Maintenance, Replacement, and Delivery. 
 
The rules say that a knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints 
(L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-
lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury 
to or a surgical procedure on the knee(s).  
 
The rules also say that knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a 
beneficiary who is ambulatory and has knee instability due to a condition specified in the ICD-10 Codes that 
Support Medical Necessity Group 4 Codes section. Knee instability must be documented by examination of the 
beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer 
test). Claims will be denied as not reasonable and necessary when the beneficiary does not meet the above 
criteria for coverage.  
You can find this rule at Local Coverage Determination (LCD): Knee Orthoses (L33318). 
 
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.