Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forparenteral nutrition solution, per 10 grams lipids (B4185), parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein -premix (B4197), parenteral nutrition supply kit; premix, per day (B4220), parenteral nutrition administration kit, per day (B4224), parenteral nutrition infusion pump, portable (B9004) and IV pole (E0776) provided to the enrollee from November 27, 2019 through December 3, 2019.You asked the Plan to pay forthe durable medical equipment (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 durable medical equipment (DME) have not been met.Healthcare Common Procedure Coding System (HCPCS) code B4185 (45 Units) remains not supported.  The documentation submitted did not include a valid physician order with length of need for the billed date of service. Therefore, the billed service cannot be verified.  It is noted that multiple attempts were made to contact the provider for additional information.  Healthcare Common Procedure Coding System (HCPCS) code B4197(7Units) remains not supported. The documentation submitted did not include a valid physician order with length of need for the billed date of service. Therefore, the billed service cannot be verified.  It is noted that multiple attempts were made to contact the provider for additional information.  Healthcare Common Procedure Coding System (HCPCS) code B4220 (7 Units) remains not supported.  The documentation submitted did not include a valid physician order with length of need for the billed date of service. Therefore, the billed service cannot be verified.  It is noted that multiple attempts were made to contact the provider for additional information.  Healthcare Common Procedure Coding System (HCPCS) code B4224 (7 Units) remains not supported.  Thedocumentation submitted did not include a valid physician order with length of need for the billed date of service. Therefore, the billed service cannot be verified.  It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code E0776 RR (1 Unit) remains not supported.  The documentation submitted did not include a valid physician order with length of need for the billed date of service. Therefore, the billed service cannot be verified.  It is noted that multiple attempts were made to contact the provider for additional information.  Healthcare Common Procedure Coding System (HCPCS) code B9004 RR(1 Unit) remains not supported.  The documentation submitted did not include a valid physician order with length of need for the billed date of service. Therefore, the billed service cannot be verified.  It is noted that multiple attempts were made to contact the provider for additional information.Therefore, we decided that the Plan does not have to pay forparenteral nutrition solution, per 10 grams lipids (B4185), parenteral nutrition solution; compounded amino acid and carbohydrates with electrolytes, trace elements and vitamins, including preparation, any strength, 74 to 100 grams of protein -premix (B4197), parenteral nutrition supply kit; premix, per day (B4220), parenteral nutrition administration kit, per day (B4224), parenteral nutrition infusion pump, portable (B9004) and IV pole (E0776) provided to the enrollee from November 27, 2019 through December 3, 2019.