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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 orthopedic shoes and other supportive devices for the feet generally are not covered. 
However, this exclusion does not apply to such a shoe if it is an integral part of a leg brace, and its expense is 
included as part of the cost of the brace. Also, this exclusion does not apply to therapeutic shoes furnished to 
diabetics. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, 
Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 290(3). 
 
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 
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. 
 
The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or 
carrier sufficient information to determine whether payment is due and the amount of payment. You can find 
this rule at 42 CFR 424.5. 
 The rules say for Medicare to consider coverage and payment for any item or service, the information 
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical 
documentation and confirm that Medicare coverage criteria have been met. You can see this in the Centers for 
Medicare and Medicaid Services, Internet Only Manual, Publication 100-08, Medicare Program Integrity 
Manual Chapter 3, 3.3.2.1. 
 
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.