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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 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 Sections 411.15 and 
411.15(o). 
 
The rules say that indications for coverage include: 
 The treatment of primary immunodeficiency syndromes associated with defects in humoral immunity to 
replace or boost immunoglobulin G (IgG) 
 The treatment of idiopathic thrombocytopenic purpura (ITP) when a rapid rise in the platelet count is 
required such as prior to surgery, to control excessive bleeding, or to defer or avoid splenectomy 
 Treatment of Kawasaki disease, in conjunction with aspirin 
 Prevention of recurrent bacterial infections in patients with hypogammaglobulinemia associated with B-
cell chronic lymphocytic leukemia (CLL) 
 Decreasing risk of acute graft-vs.-host disease, associated interstitial pneumonia, and infections after 
bone marrow transplant in the first 100 days after transplantation 
 Reducing the risk of severe bacterial infections in human immunodeficiency virus (HIV) infected 
children with a CD4 count of greater than 200 to 400 
 Second-line treatment of certain autoimmune myopathies 
 The treatment of adults with Guillain-Barre syndrome diagnosed within the first 2 weeks of illness 
 Treatment of hyperimmunoglobulinemia E syndrome and Lambert-Eaton myasthenic syndrome 
(LEMS) 
 Treatment of multifocal motor neuropathy (MMN) 
 Treatment of relapsing-remitting multiple sclerosis  Treatment of chronic parvovirus B19 infection and severe anemia associated with bone marrow 
suppression and pure red cell aplasia 
 Treatment of progressive pemphigus vulgaris, pemphigus foliaceus, bullous pemphigoid, mucous 
membrane pemphigoid, and epidermolysis bullosa acquisita in patients that have failed conventional 
treatment and patients in whom conventional therapy is otherwise contraindicated 
 For coverage criteria of Autoimmune Mucocutaneous Blistering Diseases, please see CMS Internet-
Only Manual, Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, 
250.3 
 Treatment of stiff person syndrome 
 Treatment of Myasthenia Gravis (MG) in patients who have profound, rapidly progressive and/or 
potentially life-threatening muscular weakness and are refractory to, or intolerant of cholinesterase 
inhibitors, corticosteroids and azathioprine 
 The prevention and/or treatment of organ rejection in patients sensitized to living or cadaveric organ 
donors 
 Schonlein-Henoch 
 Treatment of Paraneoplastic Visual Loss 
 Treatment of Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) in patients meeting the 
necessary criteria 
 Treatment of Multiple Myeloma for the prevention of life-threatening infections due to reduced gamma 
globulins 
You can find this information in Local Coverage Determination (LCD) Intravenous Immunoglobulin (IVIG) 
L34580. 
 
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.