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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 CFR 422.101.
Medicare guidance says the supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) is required to keep on file a physician prescription (order). A supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary." In addition; "All DMEPOS items other than those referenced in 42 CFR 410.38(c)(4) and 410.38(g)(2) require detailed written orders prior to billing. Detailed written orders may take the form of a photocopy, facsimile image, electronically maintained, or original ""pen-and-ink"" document. (See chapter 3, section 3.3.2.4). The written order must be sufficiently detailed, including all options or additional features that will be separately billed or that will require an upgraded code. The description can be either a narrative description (e.g., lightweight wheelchair base) or a brand name/model number. All orders must clearly specify the start date of the order." Also, "A written order prior to delivery is required for certain DMEPOS items as specified in 42 CFR 410.38(c)(4) and 410.38(g)(2). For these items, the supplier must have received a written order that has been both signed and dated by the treating physician/practitioner before dispensing the item. If a supplier bills for an item without a written order prior to delivery, the item will be denied." "For a covered DME item, outlined in 42 CFR 410.38(g), the contractor shall ensure that the written order is consistent with requirements in 42 CFR 410.38(g)(4). This order must include, the beneficiary's name, the item of DME ordered, the NPI of the prescribing physician/practitioner, the signature of the prescribing physician/practitioner and the date of the order. If this information is not included on the written order, the claim will be denied. Medicare requires that the written order is completed after the face-to-face encounter. If the date of the written order is prior to the date of the face-to-face encounter, the contractor shall deny the claim. Section 424.57(c)(12) requires suppliers, as part of their standards to be met for enrollment and participation, to maintain proof of delivery documentation in their files. In certain instances, compliance with proof of delivery may be required as a condition of payment, and must be available to the DME MAC, RAC, SMRC, CERT, and ZPIC/UPIC on request. For such items, if the supplier does not have appropriate proof of delivery documentation within the prescribed timeframes, associated claims will be denied and overpayments recouped. We note that non-compliance with supplier standards may also result in revocation from the Medicare program. Suppliers who consistently do not provide documentation to support their services may be referred to the OIG or NSC for investigation and/or imposition of sanctions. If the beneficiary is newly eligible to the Medicare program, the proof of delivery standards require the supplier to obtain a statement, signed and dated by the beneficiary (or beneficiary's designee), that the supplier has examined the item."""" Also, "Any person who can sign and accept the delivery of durable medical equipment on behalf of the beneficiary." Suppliers, their employees, or anyone else having a financial interest in the delivery of the item are prohibited from signing and accepting an item on behalf of a beneficiary (i.e., acting as a designee on behalf of the beneficiary). The signature of the designee should be legible. If the signature of the designee is not legible, the supplier/shipping service should note the name of the designee on the delivery slip. Three methods of delivery are: Supplier delivering directly to the beneficiary or designee; Supplier utilizing a delivery/shipping service to deliver items; and Delivery of items to a nursing facility on behalf of the beneficiary. "The date of delivery may be entered by the beneficiary, designee or the supplier. As a general Medicare rule, the date of service shall be the date of delivery. Exceptions are made for suppliers who use a delivery/shipping service. If the supplier uses a delivery/shipping service, the supplier may use the shipping date as the date of service on the claim. The shipping date may be defined as the date the delivery/shipping service label is created or the date the item is retrieved for delivery; however, such dates
should not demonstrate significant variation. (See Pub. 100-08, chapter 5, section 5.2.4 for further information on written orders prior to delivery. You can find this guidance in the Medicare Benefit Policy Manual, Chapter 15 - Covered Medical and Other Health Services, Section 110.2 - Repairs, Maintenance, Replacement, and Delivery, Paragraph C. -Replacement; Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Action, Section 3.3.2.1 - Documents on Which to Base a Determination; National Correct Coding Initiative Policy Manual for Medicare Services, Chapter 1 - General Correct Coding Policies, Section A. - Introduction, pages I-7 and I-8 and Chapter 12 - Supplemental Services HCPCS Level II Codes A0000 - V9999, Section A. - Introduction, page XII-3; Medicare Program Integrity Manual, Chapter 5 - Items and Services Having Special DME Review Considerations, Section 5.2.1 - Physician Orders, Section 5.2.3 - Detailed Written Orders and Section 5.2.4 - Written Orders Prior to Delivery, Paragraph A. - General and Paragraph C. - Written Orders for Certain Covered Durable Medical Equipment (DME) Items; and Section 5.8 - Supplier Documentation; Medicare Program Integrity Manual, Chapter 4 - Program Integrity, Section 4.26.1 - Proof of Delivery and Delivery Methods.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.