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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 heavy duty and bariatric devices are included in the codes for pressure reducing support 
surfaces: E0193, E0277, E0371, E0372 and E0373. 
 
Code E0277 describes a powered pressure reducing mattress (alternating pressure, low air loss, or powered 
flotation without low air loss) which is characterized by all of the following: 
 
    An air pump or blower which provides either sequential inflation and deflation of the air cells or a low 
interface pressure throughout the mattress, and 
    Inflated cell height of the air cells through which air is being circulated is 5 inches or greater, and 
    Height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for 
alternating pressure mattresses), and air pressure provide adequate beneficiary lift, reduce pressure and prevent 
bottoming out, and 
    A surface designed to reduce friction and shear, and 
    Can be placed directly on a hospital bed frame. 
 
Either alternating pressure mattresses or low air loss mattresses are coded using code E0277. 
 
Products containing multiple components are categorized according to the clinically predominant component 
(usually the topmost layer of a multi-layer product). For example, a product with 3" powered air cells on top of 
a 3" foam base would be coded as a powered overlay (code E0181) not as a powered mattress (E0277). 
You can find these rules in the Local Coverage Article Pressure Reducing Support Surfaces - Group 2 - Policy 
Article A52490. 
 
The rules say that a non-segmented pneumatic compressor (E0650) is a device that has a single outflow port on 
the compressor. Pressurized air from the single outflow port is transmitted to an appliance with single or 
multiple segments. The segment(s) inflate and deflate based on the compressor-specified pressure and cycle 
times. The number of segments contained in the appliance does not affect HCPCS coding of the compressor. 
Appliances appropriate for use with an E0650 PCD are E0655, E0660, E0665, E0666, E0671, E0672 and 
E0673. All limb appliances (E0655, E0660, E0665, E0667, E0668, E0669, E0670, E0671, E0672, E0673) used with 
PCDs E0650, E0651, E0652 must enclose the affected limb(s) sufficiently to prevent retrograde edema fluid 
flow (distally). All limb appliances (E0655, E0660, E0665, E0667, E0668, E0669, E0670, E0671, E0672, 
E0673) used with PCDs E0650, E0651, E0652 must avoid a tourniquet effect during compression that would 
prevent distal fluid from moving proximally. Appliances that create a tourniquet effect or cause retrograde flow 
of edema fluid must be coded A4600 - sleeve for intermittent limb compression device, replacement only, each. 
 
HCPCS code A4600  sleeve for intermittent limb compression device, replacement only, each is used only 
when the appliance used with an E0676 device is being replaced. HCPCS codes E0655, E0656, E0657, E0660, 
E0665, E0666, E0667, E0668, E0669, E0670, E0671, E0672, E0673 must not be used when billing for 
appliances used with E0676 devices. You can find these rules in the Local Coverage Article Pneumatic 
Compression Devices - Policy Article A52488. 
 
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.