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Decision: unknown

 
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 all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of 
delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The 
supplier should also obtain as much documentation from the patient's medical record as they determine they 
need to assure themselves that coverage criteria for an item have been met. If the information in the patient's 
medical record does not adequately support the medical necessity for the item, the supplier is liable for the 
dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has 
been obtained. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. 
 
The rules say more than 2 test (diagnostic) sockets (L5618, L5620, L5622, L5624, L5626, L5628) for an 
individual prosthesis are not reasonable and necessary unless there is documentation in the medical record 
which justifies the need. Exception: A test socket is not reasonable and necessary for an immediate prosthesis 
(L5400, L5410, L5420, L5430, L5450, L5460). You can find this information in the Local Coverage 
Determination (LCD) Lower Limb Prostheses L33787. 
 
The rules say 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 CMNs. The 
medical record is not limited to treating physician/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: supplier-produced records, even if signed by the prescribing physician/practitioner, 
and attestation letters (e.g., letters of medical necessity) are deemed not to be part of a medical record for 
Medicare payment purposes.  Templates and forms, including CMS CMNs, are subject to corroboration with information in the medical record. 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. In addition to the general requirements discussed above, 
certain DMEPOS items may have specific documentation requirements. Details regarding these policy specific 
requirements are contained in the applicable LCD-related Policy Article. 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. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.