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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 in the event of a claim review, information contained directly in the contemporaneous medical record is the source required to justify payment except as noted elsewhere for prescriptions and certificates of medical necessity. The medical record is not limited to treating practitioner's 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. DMEPOS suppliers are reminded that: 1. Supplier-produced records, even if signed by the treating practitioner, and attestation letters (e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes. 2. Templates and forms, including CMS CMNs, are subject to corroboration with information in the medical record. 3. A prescription is not considered to be part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record. You can find this rule in the Local Coverage Determination (LCD) - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) - Effective April 6, 2020. The rules say that in order to justify payment for DMEPOS items, suppliers must meet the following requirements: 1. Standard Written Order 2. Medical Record Information 3. Correct Coding 4. Proof of Delivery You can find this rule in the Local Coverage Determination (LCD) - Lower Limb Prostheses (L33787) - Effective January 1, 2020. The rules say that replacement refers to the provision of an identical or nearly identical item. Equipment which the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage.
Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood). A physician's order and/or new Certificate of Medical Necessity (CMN), when required, is needed to reaffirm the medical necessity of the item. Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot be identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful lifetime of the equipment. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 100.2. The rules say that the reasonable useful lifetime of durable medical equipment is determined through program instructions. In the absence of program instructions, A/B MACs may determine the reasonable useful lifetime of equipment, but in no case can it be less than five years. You can find this rule in the Medicare Benefit Policy Manual, Chapter 15, Section 100.2.
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.