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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 coverage is extended only if there is sufficient clinical documentation of functional need for the 
technologic or design feature of a given type of knee. This information must be retained in the treating 
practitioner's or prosthetist's files." "Coverage is extended only if there is sufficient clinical documentation of 
functional need for the technologic or design feature of a given type of foot. This information must be retained 
in the treating practitioner's or prosthetist's files. You can find this information in Medicare's Local Coverage 
Determination (LCD): Lower Limb Prostheses (L33787). 
 
The rules say this section applies to MACs, CERT, Recovery Auditors, and ZPICs, as indicated. "CMS issues 
national coverage determinations (NCDs) that specify whether certain items, services, procedures or 
technologies are reasonable and necessary under 1862(a) (1) (A) of the Act. In the absence of an NCD, 
Medicare contractors are responsible for determining whether services are reasonable and necessary. If no local 
coverage determination (LCD) exists for a particular item or service, the MACs, CERT, Recovery Auditors, 
and ZPICs shall consider an item or service to be reasonable and necessary if the item or service meets the 
following criteria: 
It is safe and effective; 
It is not experimental or investigational; and 
It is appropriate, including the duration and frequency in terms of whether the service or item is: 
Furnished in a setting appropriate to the beneficiary's medical needs and condition; 
Ordered and furnished by qualified personnel; and, 
One that meets, but does not exceed, the beneficiary's medical need. You can find this information in the 
Medicare Program Integrity Manual: Chapter 3 -Verifying Potential Errors and Taking Corrective Actions, pp. 
67 and 68 of 113. 
 
The rules say MEDICAL RECORD DOCUMENTATION: 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 Medicare's Local Coverage Article: 
Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426). 
 
The rules say the payment amount for a given service or item, whether rented or purchased, must be consistent 
with what is reasonable and medically necessary to serve the intended purpose (See the Medicare Benefit 
Policy Manual, Chapter 15). Additional expenses for "deluxe" features, or items that are rented or 
purchased for aesthetic reasons or added convenience, do not meet the reasonableness test. Thus, where a 
service or item is medically necessary and covered under the Medicare program, and the patient wishes to 
obtain such deluxe features, the payment is based upon the payment amount for the kind of service or item 
normally used to meet the intended purpose (i.e., the standard item.) You can find this information in the 
Medicare Claims Processing Manual Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and 
Supplies (DMEPOS) p. 42 of 115. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.