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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 a total electric hospital bed (E0265, E0266, E0296, and E0297) is not covered; the height 
adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary. 
You can find this information in Medicare's Local Coverage Determination (LCD): Hospital Beds and 
Accessories (L33820).  
 
The rules say that 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.) Usually this is the least costly item. DME 
MACs may, of course, determine that the payment amount for a more expensive service or item is reasonable 
when the additional expense is for an added feature that is medically necessary in a given case. For example, a 
more expensive item may be medically necessary where a patient in a weakened condition needs a power- 
operated wheelchair or a power-operated vehicle that may be appropriately used as a wheelchair since the 
patient is not strong enough to operate a manual wheelchair. Finally, the provider may not charge the 
beneficiary for features not medically required by his/her condition and which cannot be considered in 
determining the provider's allowable costs unless the beneficiary or her/his representative has specifically 
requested the excessive or deluxe items or services with knowledge of the amount s/he is to be charged. 
An Advance Beneficiary Notification (ABN) is required as documentation that the beneficiary has made such 
an informed request. See Chapter 30 for ABN requirements. The acceptance of an assignment binds the 
supplier-assignee to accept the allowed charge for the medically required equipment or service as the full 
charge and he cannot charge the beneficiary the differential attributable to the equipment actually furnished. 
Only if a more expensive item or model with special features is medically necessary for the beneficiary will the 
allowed charge be based on the more expensive model. If the patient purchases or rents an item of durable 
medical equipment having more expensive features than his condition requires, the supplier accepting 
assignment on such an item cannot charge or collect any amount in excess of the allowed charge for the 
appliance adequate for the patient's needs. Acceptance of assignment binds the supplier to accept the allowed 
charge determined by the DME MAC, as the full charge for the item. A supplier who wishes to charge and 
collect the full price for equipment more expensive than medically required by the patient need not accept 
assignment.  
 In assignment cases, the beneficiary is responsible for paying the supplier the unpaid balance of the allowed 
charge when payments stop because his condition has changed, and the equipment is no longer medically 
necessary. Similarly, when payments stop because the beneficiary dies, his/her estate is responsible to the 
supplier for such unpaid balance. You can find this information in the Medicare Claims Processing Manual 
Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS); 90 - Payment for 
Additional Expenses for Deluxe Features. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.