Appeal type: unknown
Decision: unknown

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 all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The supplier should also obtain as much documentation from the patient's medical record as they determine they need to assure themselves that coverage criteria for an item have been met. If the information in the patient's medical record does not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has been obtained. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. PCDs coded as E0650, E0651, E0652 are used only in the treatment of lymphedema or for the treatment of chronic venous insufficiency with venous stasis ulcers. Reimbursement for these items is based upon the criteria in the following sections. PCD coded as E0675 is used in the treatment of peripheral arterial disease. Claims for E0675 will be denied as not reasonable and necessary as outlined below. I - LYMPHEDEMA A PCD coded as E0650 or E0651 is covered for both primary and secondary lymphedema in beneficiaries with chronic and severe lymphedema when all of the following three requirements are met: 1. The beneficiary has a diagnosis of lymphedema as defined above, and 2. The beneficiary has persistence of chronic and severe lymphedema as identified by the documented presence of at least one of the following clinical findings: a. Marked hyperkeratosis with hyperplasia and hyperpigmentation, b. Papillomatosis cutis lymphostatica,
c. Deformity of elephantiasis,
d. Skin breakdown with persisting lymphorrhea,
e. Detailed measurements over time confirming the persistence of the lymphedema with a history
evidencing a likely etiology, and
3. In addition to this documented persistence, the lymphedema is then documented to be unresponsive to
other clinical treatment over the course of a required four-week trial. (See below for trial guidelines.)
A PCD coded as E0650 or E0651 used to treat lymphedema that does not meet all of the requirements above is
not eligible for reimbursement. Claims will be denied as not reasonable and necessary.
A PCD coded as E0650 or E0651 used to treat edema from causes other than lymphedema is not eligible for
reimbursement. Claims will be denied as not reasonable and necessary.
You can find this information in Local Coverage Determination (LCD): Pneumatic Compression Devices
(L33829.
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.