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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 these appliances are covered under Part B when furnished incident to physicians services 
or on a physicians order. A brace includes rigid and semi-rigid devices which are used for the purpose of 
supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part 
of the body. Elastic stockings, garter belts, and similar devices do not come within the scope of the definition 
of a brace. Back braces include, but are not limited to, special corsets, e.g., sacroiliac, sacrolumbar, 
dorsolumbar corsets, and belts. A terminal device (e.g., hand or hook) is covered under this provision whether 
an artificial limb is required by the patient. Stump stockings and harnesses (including replacements) are also 
covered when these appliances are essential to the effective use of the artificial limb. Adjustments to an 
artificial limb or other appliance required by wear or by a change in the patients condition are covered when 
ordered by a physician. Adjustments, repairs and replacements are covered even when the item had been in use 
before the user enrolled in Part B of the program so long as the device continues to be medically required. 
 
You can find this information in the Medicare Benefit Policy Manual Chapter 15 Section 130 
 
Healthcare Common Procedure Coding System (HCPCS) CODING 
 
The Medicare Program Integrity Manual (CMS Pub. 100-08), Chapter 3, Sections 3.3.B and 3.6.2.4 specify that 
for Medicare claims, only CMS and the Durable Medical Equipment Medicare Administrative Contractors 
(DME MACs) have the authority to establish HCPCS Level II Coding Guidelines. Pursuant to 42 CFR  
414.40 and 45 CFR  162.1002, CMS has the authority to assign and manage HCPCS codes (create, delete, 
change code narrative etc.). The DME MACs have the authority to evaluate products to make benefit category 
and coding determinations for any DME item that does not logically fall into any of the generic categories 
listed in NCD 280.1. 
 
Correct HCPCS coding is a determination that the item provided to a beneficiary is billed using the appropriate 
HCPCS code for that item. Suppliers are required to correctly code for the item billed. An item/service is 
correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related 
Policy Articles, or DME MAC articles. 
 
The Pricing, Data Analysis, and Coding (PDAC) contractor maintains product listings for many HCPCS codes 
on their website  
 
 (Select, DMECS to search for HCPCS codes and associated product lists). Not every HCPCS code has a 
product classification list; but reviewed products are added to the listings for each code as coding 
determinations are completed. For Medicare claim purposes, this product classification listing is accepted as 
evidence of correct coding. 
 
Each supplier is ultimately responsible for the HCPCS code they select to bill for the item provided. Resources 
such as LCDs, LCD-related Policy Articles, DME MAC articles, code determinations letters and DMECS are 
useful; but many products currently on the market have not been reviewed. For these un-reviewed products, 
each supplier must use their best judgment in selecting HCPCS codes for billing and are encouraged to check 
with The PDAC Contact Center, which can provide information that will assist in correct code selection. 
 
Information that is sufficiently detailed to unambiguously identify the specific product delivered to the 
beneficiary and the HCPCS code used to bill for that item must be maintained by the supplier and be available 
upon request. 
 
You can find this information in the Local Coverage Article Standard Documentation Requirements for All 
Claims Submitted to DME MACs A55426. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.