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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 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 also say the statutory coverage criteria for therapeutic shoes including the requirement for an order 
are specified in the related Policy Article. 
 
Separate inserts may be covered and dispensed independently of diabetic shoes if the supplier of the shoes 
verifies in writing that the beneficiary has appropriate footwear into which the insert can be placed. This 
footwear must meet the definitions found in this policy for depth shoes or custom-molded shoes. 
 
A custom molded shoe (A5501) is covered when the beneficiary has a foot deformity that cannot be 
accommodated by a depth shoe. The nature and severity of the deformity must be well documented in the 
supplier's records and available upon request. If a custom molded shoe is provided but the medical record does 
not document why that item is medically necessary, it will be denied as not reasonable and necessary. 
 
GENERAL 
For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a 
Written Order Prior to Delivery (WOPD), the supplier must have received a signed Standard Written Order 
(SWO) before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without 
first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related 
Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section. 
 
For DMEPOS base items that require a WOPD, and also require separately billed associated options, 
accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may 
list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the 
items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies 
without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be 
denied as not reasonable and necessary. 
 
An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, 
LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be 
denied as not reasonable and necessary/incorrectly coded. 
 
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD 
documentation in their files. Proof of delivery documentation must be made available to the Medicare 
contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be 
denied as not reasonable and necessary. You can find this information in the Local Coverage Determination 
(LCD): Therapeutic Shoes for Persons with Diabetes (L33369). 
 
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.