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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 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 
certificates of medical necessity (CMNs) (for dates of service prior to January 1, 2023). The medical record is 
not limited to treating practitioners 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. Durable Medical Equipment, Prosthetics, 
Orthotics and Supplies (DMEPOS) suppliers are reminded that: 
 
    - Supplier-produced records, even if signed by the treating practitioner, and attestation letters are deemed not 
to be part of a medical record for Medicare payment purposes. 
    - Templates and forms, including Centers for Medicare & Medicaid Services (CMS) CMNs prior to DOS 
January 1, 2023, 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. 
    - The beneficiarys medical record must contain sufficient documentation of the beneficiarys 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 beneficiarys diagnosis and other pertinent 
information including, but not limited to, duration of the beneficiarys condition, clinical course (worsening or 
improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and 
results, past experience with related items, et cetera.  
You can find this information in the Local Coverage Article (LCA): Standard Documentation Requirements for 
All Claims Submitted to DME MACs (A55426). 
 
The rules say that for any durable medical equipment, prosthetics, orthotics and supplies (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 certificate of medical necessity (CMN) or 
durable medical equipment (DME) information form (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). 
 
You can find this information in the Centers for Medicare and Medicaid Service, Internet-Only Manual, 
Publication 100-08, Medicare Program Integrity Manual, Chapter 5  Items and Services Having Special DME 
Review Considerations, Section 5.9  Documentation in the Patients Medical Record.  
 
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.