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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 medically necessary services are those that are reasonable and necessary for the diagnosis or 
treatment of an illness or injury. Medically necessary services include services to improve the functioning of a 
malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A). 
 
The rules say that permanent cardiac pacemakers refer to a group of self-contained, battery operated, implanted 
devices that send electrical stimulation to the heart through one or more implanted leads. They are often 
classified by the number of chambers of the heart that the devices stimulate (pulse or depolarize). Single 
chamber pacemakers typically target either the right atrium or right ventricle. Dual chamber pacemakers 
stimulate both the right atrium and the right ventricle. 
 
The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is sufficient to 
conclude that implanted permanent cardiac pacemakers, single chamber, or dual chamber, are reasonable and 
necessary for the treatment of non-reversible symptomatic bradycardia due to sinus node dysfunction and 
second and/or third-degree atrioventricular block. Symptoms of bradycardia are symptoms that can be directly 
attributable to a heart rate less than 60 beats per minute (for example: syncope, seizures, congestive heart 
failure, dizziness, or confusion). 
 
The following indications are covered for implanted permanent single chamber or dual chamber cardiac 
pacemakers: 
 
    Documented non-reversible symptomatic bradycardia due to sinus node dysfunction, and 
    Documented non-reversible symptomatic bradycardia due to second degree and/or third degree 
atrioventricular block. 
 
The following indications are non-covered for implanted permanent single chamber or dual chamber cardiac 
pacemakers: 
 
    Reversible causes of bradycardia such as electrolyte abnormalities, medications or drugs, and hypothermia, 
    Asymptomatic first degree atrioventricular block, 
    Asymptomatic sinus bradycardia, 
    Asymptomatic sino-atrial block or asymptomatic sinus arrest, 
    Ineffective atrial contractions (e.g., chronic atrial fibrillation or flutter, or giant left atrium) without 
symptomatic bradycardia,     Asymptomatic second degree atrioventricular block of Mobitz Type I unless the QRS complexes are 
prolonged or electrophysiological studies have demonstrated that the block is at or beyond the level of the His 
Bundle (a component of the electrical conduction system of the heart), 
    Syncope of undetermined cause, 
    Bradycardia during sleep, 
    Right bundle branch block with left axis deviation (and other forms of fascicular or bundle branch block) 
without syncope or other symptoms of intermittent atrioventricular block, 
    Asymptomatic bradycardia in post-myocardial infarction patients about to initiate long-term beta-blocker 
drug therapy, 
    Frequent or persistent supraventricular tachycardias, except where the pacemaker is specifically for the 
control of tachycardia, and 
    A clinical condition in which pacing takes place only intermittently and briefly, and which is not associated 
with a reasonable likelihood that pacing needs will become prolonged. 
 
You can find these rules in the National Coverage Determination (NCD) Cardiac Pacemakers: Single Chamber 
and Dual Chamber Permanent Cardiac Pacemakers 20.8.3. 
 
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.