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Decision: unknown

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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).  
 
The rules say that services that are not medically necessary are not covered. The rules also say that 
experimental and investigational devices are not covered. You can find this rule at 42 CFR 411.15 and 
411.15(o). 
 
Medicare guidance says the supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies 
(DMEPOS) is required to keep on file a physician prescription (order). A supplier must have an order from the 
treating physician before dispensing any DMEPOS item to a beneficiary.? In addition; ?All DMEPOS items 
other than those referenced in 42 CFR 410.38(c)(4) and 410.38(g)(2) require detailed written orders prior to 
billing. Detailed written orders may take the form of a photocopy, facsimile image, electronically maintained, 
or original ""pen-and-ink"" document. (See chapter 3, section 3.3.2.4). The written order must be sufficiently 
detailed, including all options or additional features that will be separately billed or that will require an 
upgraded code. The description can be either a narrative description (e.g., lightweight wheelchair base) or a 
brand name/model number. All orders must clearly specify the start date of the order.? Also, ?A written order 
prior to delivery is required for certain DMEPOS items as specified in 42 CFR 410.38(c)(4) and 410.38(g)(2). 
For these items, the supplier must have received a written order that has been both signed and dated by the 
treating physician/practitioner before dispensing the item. If a supplier bills for an item without a written order 
prior to delivery, the item will be denied.? ?For a covered DME item, outlined in 42 CFR 410.38(g), the 
contractor shall ensure that the written order is consistent with requirements in 42 CFR 410.38(g)(4). This 
order must include, the beneficiary?s name, the item of DME ordered, the NPI of the prescribing 
physician/practitioner, the signature of the prescribing physician/practitioner and the date of the order. If this 
information is not included on the written order, the claim will be denied. Medicare requires that the written 
order is completed after the face-to-face encounter. If the date of the written order is prior to the date of the 
face-to-face encounter, the contractor shall deny the claim. You can find this guidance in the Medicare 
Program Integrity Manual Chapter 5 ? Items and Services Having Special DME Review Considerations, 5.2.1 - 
Physician Orders, 5.2.3 ? Detailed Written Orders and 5.2.4 ? Written Orders Prior to Delivery (A and C).C11. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.