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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 Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Guidance Manual, Section 50.12.1. 
 
For capped rental items of durable medical equipment (DME), contractors pay the fee schedule amounts on a 
monthly rental basis not to exceed a period of continuous use of 15 months. In the tenth month of rental, the 
beneficiary is given a purchase option (see 30.5.2). If the purchase option is exercised, contractors continue to 
pay rental fees not to exceed a period of continuous use of 13 months and ownership of the equipment passes to 
the beneficiary. If the purchase option is not exercised, contractors continue to pay rental fees until the 15-
month cap is reached and ownership of the equipment remains with the supplier (see 30.5.4). In the case of 
electric wheelchairs only, the beneficiary must be given a purchase option at the time the equipment is first 
provided (see 30.5.3). You can find this rule in the Centers for Medicare & Medicaid Services, Internet Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 30.5. 
 
Effective May 1, 1991, suppliers must give beneficiaries the option of converting their capped rental equipment 
to purchased equipment during their 10th continuous rental month. Contractors make no further rental 
payments after the 11th rental month for capped rental items until the supplier notifies the contractor that it has 
contacted the beneficiary and furnished him/her with the option of either purchase or continued rental. 
Information contained in Exhibit 1 may be furnished to beneficiaries by suppliers to help them make a 
rent/purchase decision. Contractors provide copies of Exhibit 1 to suppliers. Beneficiaries have one month 
from the date the supplier makes the offer to accept this option. If the beneficiary declines or fails to respond to 
the purchase option, the contractor continues to make rental payments until the 15-month rental cap is reached. 
 
If the beneficiary accepts the purchase option, the contractor continues making rental payments until a total of 
13 continuous rental months have been paid. The contractor will not make any additional rental payments 
beyond the 13th rental month. On the first day after 13 continuous rental months have been paid, the supplier 
must transfer title to the equipment to the beneficiary. You can find this rule in the Centers for Medicare & 
Medicaid Services, Internet Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 
20, Section 30.5.2. 
 
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.