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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 for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1.  
 
The rules say that the medical record is not limited to treating practitioners office records but may include 
records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all-
inclusive). Records from suppliers or healthcare professionals with a financial interest in the claim outcome are 
not considered sufficient by themselves for determining that an item is reasonable and necessary. You can find 
this information in the  Local Coverage Article: Standard Documentation Requirements for All Claims 
Submitted to DME MACs (A55426). 
 
For any durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) item to be covered by 
Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition 
to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or 
replacement (if applicable). The information should include the patient's diagnosis and other pertinent 
information including, but not limited to, duration of the patient's condition, clinical course (worsening or 
improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and 
results, past experience with related items, etc. If an item requires a certificate of medical necessity (CMN) or 
DME information form (DIF), it is recommended that a copy of the completed CMN or DIF be kept in the 
patient's record. However, neither a physician's order, nor a CMN, nor a DIF, nor a supplier prepared 
statement, nor a physician attestation by itself provides sufficient documentation of medical necessity, even 
though it is signed by the treating physician or supplier. There must be information in the patient's medical 
record that supports the medical necessity for the item and substantiates the answers on the CMN (if 
applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if 
applicable). You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5  Items and Services Having 
Special DME Review Considerations, Section 5.9  Documentation in the Patients Medical Record.  
The rules say that a flex-walk system or equal (L5981) is covered when medically necessary and for 
beneficiaries whose functional level is 3 or above. You can find this information in the Local Coverage 
Determination (LCD): Lower Limb Prostheses (L33787). 
 
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.