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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 Sections 411.15 and 
411.15(o). 
 
The rules say that items that do not contribute meaningfully to the treatment of an illness or injury or the 
functioning of a malformed body member are not covered. 
 
Charges for special items requested by the patient such as radio, television, telephone, and air conditioner, and 
beauty and barber services are excluded from coverage. The patient may be charged for such a service if they 
requested it with knowledge that they will be charged. To avoid misunderstanding and disputes, the provider 
informs the individual upon request for such an item or service that there is a specified charge (not exceeding 
the customary charge). Thereafter, the provider may not charge the patient more for the item or service than the 
charge specified. A provider may not require a beneficiary to request noncovered items or services as a 
condition of admission or of continued stay. 
 
Basic personal services such as simple barber and beautician services (e.g., shaves, haircuts, shampoos, and 
simple hair sets) which patients need and cannot perform for themselves may be viewed as ordinary patient 
care when furnished by a long-stay institution. Such services are covered costs reimbursable under Part A when 
included in the flat rate charge and provided routinely without charge to the patient by an SNF or by a general 
psychiatric or tuberculosis hospital. The services are maintenance of at least a minimum level of personal 
hygiene, decency, and presentability items essential to the well-being of the patient and of other patients who must associate with the patient. However, under the personal comfort exclusion, more elaborate services, such 
as professional manicures, hair styling, etc., are excluded even when furnished routinely and without special 
charge. 
 
You can find this rule in the Centers for Medicare & Medicaid Services (CMS), Medicare Benefit Policy 
Manual, Chapter 16, Section 80. 
 
The rules say that Medicare will pay for durable medical equipment that is mainly used to serve a medical 
purpose. Items such as hospital beds, respirators, wheelchairs and crutches are examples of equipment that are 
clearly used for medical purposes. Medicare will not pay for: 
 
1. Equipment that is primarily and customarily used for nonmedical purposes. Examples include air 
conditioners, humidifiers, dehumidifiers and electric air cleaners; 
2. Equipment used for a patients comfort or for the convenience of a person caring for the patient. Examples 
include elevators, stairway elevators, physical fitness equipment and self-help devices such as grab bars. You 
can find these rules in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-
02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1. 
 
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.