Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for power wheelchair accessory, 22nf sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat) (E2361), power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each (E2392), wheelchair accessory, bearings, any type, replacement only, each (E2210), power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each (E2386), power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each (E2394) and repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes (K0739) provided to the enrollee on January 23, 2020.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.
The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. Healthcare Common Procedure Coding System (HCPCS) code E2361 NU RB KX (2 Units) remains not supported. The documentation submitted did not include documentation of valid physician order; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met. Healthcare Common Procedure Coding System (HCPCS) code E2392 NU RB KX (4 Units) remains not supported. The documentation submitted did not include documentation of valid physician order; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met. Healthcare Common Procedure Coding System (HCPCS) code E2210 NU RB KX (4 Units) remains not supported. The documentation submitted did not include documentation of valid physician order; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met.
Healthcare Common Procedure Coding System (HCPCS) code E2386 NU RB KX (2 Units) remains not supported. The documentation submitted did not include documentation of valid physician order; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met. Healthcare Common Procedure Coding System (HCPCS) code E2394 NU RB KX (2 Units) remains not supported. The documentation submitted did not include documentation of valid physician order; therefore, the billed service cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met. Healthcare Common Procedure Coding System (HCPCS) code K0739 (10 Units) remains not supported. The documentation submitted did not include documentation of describing the repair and the time that it took to complete the repair; therefore, the billed service and its units cannot be verified. It is noted that multiple attempts were made to contact the provider for additional information. We have insufficient documentation to corroborate the services so we can confirm Medicare coverage has been met. Therefore, we decided that the Plan does not have to pay for power wheelchair accessory, 22nf sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat) (E2361), power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each (E2392), wheelchair accessory, bearings, any type, replacement only, each (E2210), power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each (E2386), power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each (E2394) and repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes (K0739) provided to the enrollee on January 23, 2020