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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 state that prescriptions for Pneumatic Compression Devices (PCDs) (E0650, E0651, E0652, E0675, 
E0676) are limited to Physicians (MD, DO, DPM) and physician extenders (NP, PA, CNS) to the extent 
allowed by their applicable state scope-of-practice and other license requirements. Providers must use care 
because the treatment of lymphedema, chronic venous insufficiency with ulceration and complications related 
to the treatment of these conditions by use of PCDs, commonly require consideration of diagnoses and 
management of systemic conditions. In no event should a provider order PCDs or PCD appliances that are to be 
used for or are to be applied to areas of the body that fall outside of their state scope of practice and other 
license limitations. 
 
A PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with 
chronic and severe lymphedema when all of the following three requirements are met: 
 
    The beneficiary has a diagnosis of lymphedema as defined above, and 
    The beneficiary has persistence of chronic and severe lymphedema as identified by the documented presence 
of at least one of the following clinical findings: 
        Marked hyperkeratosis with hyperplasia and hyperpigmentation, 
        Papillomatosis cutis lymphostatica, 
        Deformity of elephantiasis, 
        Skin breakdown with persisting lymphorrhea, 
        Detailed measurements over time confirming the persistence of the lymphedema with a history evidencing 
a likely etiology, and 
    In addition to this documented persistence, the lymphedema is then documented to be unresponsive to other 
clinical treatment over the course of a required four-week trial. (See below for trial guidelines.) 
 
A PCD coded as E0650 or E0651 used to treat lymphedema that does not meet all of the requirements above is 
not eligible for reimbursement. Claims will be denied as not reasonable and necessary. 
 
A PCD coded as E0650 or E0651 used to treat edema from causes other than lymphedema is not eligible for 
reimbursement. Claims will be denied as not reasonable and necessary. The trial of conservative therapy must be documented in the beneficiarys medical record before prescribing 
any type of pneumatic compression device (E0650, E0651, E0652). This assessment may be performed by the 
treating practitioner, or any other licensed/certified medical professional (LCMP) directly involved in the 
beneficiarys lymphedema treatment. The LCMP may not have any financial relationship with the DMEPOS 
supplier providing the device. If the assessment is performed by an LCMP, the treating practitioner must 
receive and review the report of the evaluation. In addition, the treating practitioner must sign and date the 
report, and state concurrence or disagreement with the assessment. The signature date must be on or before the 
prescription date. You can find these rules in the Local Coverage Determination (LCD) Pneumatic 
Compression Devices L33829. 
 
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.