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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 say that the durable medical equipment (DME) list that follows is designed to facilitate the Medicare 
Administrative Contractors (MAC's) processing of DME claims. This section is designed as a quick reference 
tool for determining the coverage status of certain pieces of DME and especially for those items commonly 
referred to by both brand and generic names. The information contained herein is applicable (where 
appropriate) to all DME national coverage determinations (NCDs) discussed in the DME portion of this 
manual. The list is organized into two columns. The first column lists alphabetically various generic categories 
of equipment on which NCDs have been made by the Centers for Medicare & Medicaid Services (CMS); the 
second column notes the coverage status. 
 
In the case of equipment categories that have been determined by CMS to be covered under the DME benefit, 
the list outlines the conditions of coverage that must be met if payment is to be allowed for the rental or 
purchase of the DME by a particular patient, or cross-refers to another section of the manual where the 
applicable coverage criteria are described in more detail. With respect to equipment categories that cannot be 
covered as DME, the list includes a brief explanation of why the equipment is not covered. This DME list will 
be updated periodically to reflect any additional NCDs that CMS may make with regard to other categories of 
equipment. 
 
When the MAC receives a claim for an item of equipment which does not appear to fall logically into any of 
the generic categories listed, the MAC has the authority and responsibility for deciding whether those items are 
covered under the DME benefit. 
 
These decisions must be made by each MAC based on the advice of its medical consultants, taking into 
account: 
 
    a. The Medicare Claims Processing Manual, Chapter 20, "Durable Medical Equipment, Prosthetics and 
Orthotics, and Supplies (DMEPOS)." 
    b. Whether the item has been approved for marketing by the Food and Drug Administration (FDA) and is 
otherwise generally considered to be safe and effective for the purpose intended; and 
    c. Whether the item is reasonable and necessary for the individual patient. The term DME is defined as equipment which: 
 
    a. Can withstand repeated use, i.e., could normally be rented and used by successive patients; 
    b. Is primarily and customarily used to serve a medical purpose; 
    c. Generally, is not useful to a person in the absence of illness or injury; and 
    d. Is appropriate for use in a patients home. 
 
You can find this rule in the National Coverage Determination (NCD): Durable Medical Equipment Reference 
List 280.1. 
 
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.