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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. 
 
The rules say that the home health agency (HHA) must be acting upon a physician or allowed practitioner plan 
of care that meets the requirements of this section for HHA services to be covered. For HHA services to be 
covered, the individualized plan of care must specify the services necessary to meet the patient-specific needs 
identified in the comprehensive assessment. In addition, the plan of care must include the identification of the 
responsible discipline(s) and the frequency and duration of all visits as well as those items listed in 42 CFR 
484.60(a) that establish the need for such services. All care provided must be in accordance with the plan of 
care. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.2.2. 
 
The rules say that as part of the certification of patient eligibility for the Medicare home health benefit, a face-
to-face encounter with the patient must be performed by the certifying physician or allowed practitioner 
himself or herself, a physician or allowed practitioner that cared for the patient in the acute or post-acute care 
facility (with privileges who cared for the patient in an acute or post-acute care facility from which the patient 
was directly admitted to home health) or an allowed non-physician practitioner (NPP). 
 
The physician or allowed practitioner who signs the certification or recertification must be permitted to do so 
by 42 CFR 424.22. A physician or other allowed non-physician practitioner, other than the certifying physician 
or certifying allowed practitioner who established the home health plan of care, may sign the plan of care or the 
recertification statement in the absence of the certifying physician or certifying allowed practitioner.  
 
You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 
100-02, Medicare Benefit Policy Manual, Chapter 7, Sections 30.5.1.1 and 30.5.3. 
 
The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual, Chapter 3, Section 3.3.2.1. 
 
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.