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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.
Medicare guidance says "Section 1848(g)(4) of the Social Security Act requires that (the prescribing provider) submit claims for all your Medicare patients for services rendered. This requirement applies to all physicians and suppliers who provide covered services to Medicare beneficiaries. Per Medicare references listed below the rules state: "For any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient's diagnosis and other pertinent information including, but not limited to, duration of the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. If an item requires a CMN or DIF, it is recommended that a copy of the completed CMN or DIF be kept in the patient's record. However, neither a physician's order nor a CMN nor a DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient's medical record that supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if applicable)". Also, "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 ABN of possible denial has been obtained. "The civil False Claims Act (FCA) imposes civil liability on any person who knowingly submits, or causes the submission of, a false or fraudulent claim to the Federal Government. The terms "knowing" and "knowingly" mean a person has actual knowledge of the information or acts in deliberate ignorance or reckless disregard of the truth or falsity of the information related to the claim. No proof of specific intent to defraud is required to violate the civil FCA" In addition, "The Criminal Health Care Fraud Statute prohibits knowingly and willfully executing, or attempting to execute, a scheme or lie in connection with the delivery of, or payment for, health care benefits,
items, or services to either: (A) defraud any health care benefit program, or (B) obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the control of, any health care benefit program." In addition, "Abuse includes actions that may, directly or indirectly, result in: unnecessary costs to the Medicare Program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment." Per Medicare References listed below: "Providers/suppliers have an obligation, under law, to conform to the requirements of the Medicare program. Fraud committed against the program may be prosecuted under various provisions of the United States Code and could result in the imposition of restitution, fines, and, in some instances, imprisonment. In addition, a range of administrative sanctions (such as exclusion from participation in the program) and CMPs may be imposed when facts and circumstances warrant such action. Fraud may take such form as, but not limited to: Billing for services not furnished and/or supplies not provided; Billing that appears to be a deliberate application for duplicate payment for the same services or supplies, billing both Medicare and the beneficiary for the same service, or billing both Medicare and another insurer in an attempt to get paid twice; Completing Certificates of Medical Necessity for patients not personally and professionally known by the provider; Misrepresenting dates and descriptions of services furnished or the identity of the beneficiary or the individual who furnished the services." You can find this guidance in the Social Security Act Section 1848(g)(4), Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, Section 3.2.4 - Use of Claims History Information in Claim Payment Determinations, Medicare Program Integrity Manual, Chapter 5 - Items and Services Having Special DME Review Considerations, Section 5.9 - Documentation in the Patient's Medical Record and Section 5.10 - Supplier Documentation, Medicare Managed Care Manual Chapter 21-Compliance Program Guidelines, Section 20-Definitions, Medicare Payment Integrity Manual Chapter 4-Program Integrity, Section 4.2.1-Examples of Medicare Fraud, ICN MLN4649244 January 2021-Medicare Fraud & Abuse: Prevent, Detect, and Report and U.S. Code Title 31, Sections 3729-3733.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.