Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for tubing with heating element (CPT Code A4604), replacement nasal cushion (CPT Code A7032), nasal application device (CPT Code A7034), headgear used with positive airway pressure device (CPT Code A7035), filter, disposable, used with positive airway pressure device (CPT Code A7038) and delivery/set up/dispensing (CPT Code A9901) provided to the enrollee on July 2, 2019.
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.
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 A9901 (1 Unit) remains not supported. The documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified. In addition, the submitted order indicates "all supplies are included" but do not include detailed description of the supplies. It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code A7035 NU KX (1 Unit) remains not supported. The documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified. In addition, the submitted order indicates "all supplies are included" but do not include detailed description of the supplies. It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code A7034 NU KX (1 Unit) remains not supported. The documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified. In addition, the submitted order indicates "all supplies are included" but do not include detailed description of the supplies. It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code A7032 NU KX (6 Units) remains not supported. The documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified. In addition, the submitted order indicates "all supplies are included" but do not include detailed description of the supplies. It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code A7038 NU KX (6 Units) remains not supported. The documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified. In addition, the submitted order indicates "all supplies are included" but do not include detailed description of the supplies. It is noted that multiple attempts were made to contact the provider for additional information. Healthcare Common Procedure Coding System (HCPCS) code A4604 NU KX (1 Unit) remains not supported. The documentation submitted did not include a valid physician order; therefore, the billed service cannot be verified. In addition, the submitted order indicates "all supplies are included" but do not include detailed description of the supplies. 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 for tubing with heating element (CPT Code A4604), replacement nasal cushion (CPT Code A7032), nasal application device (CPT Code A7034), headgear used with positive airway pressure device (CPT Code A7035), filter, disposable, used with positive airway pressure device (CPT Code A7038) and delivery/set up/dispensing (CPT Code A9901) provided to the enrollee on July 2, 2019.