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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.
The rules say that 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, and 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 priorto 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. Forsuch 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, "If the supplier utilizes a shipping service or mail order, an example of proof of delivery would include the service's tracking slip, and the supplier's own shipping invoice. If possible, the supplier's records should also include the delivery service's package identification number for that package sent to the beneficiary. The shipping service's tracking slip should reference each individual package, the delivery address, the corresponding package identification number given by the shipping service, and if possible, the date delivered. If a supplier utilizes a shipping service or mail order, suppliers shall use the shipping date as the date of service on 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 ayment, and must be available to the DME MAC, RAC, SMRC, CERT, and
ZPIC/UPIC on request. Forsuch 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. 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 ofthe 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.) For any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient's diagnosis and other pertinent information including, but not limited to, duration of the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. If an item requires a CMN or DIF, it is recommended that a copy of the completed CMN or DIF be kept in the patient's record Per Medicare references listed below the rules state: "For any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient's diagnosis and other pertinent information including, but not limited to, duration of the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. If an item requires a CMN or DIF, it is recommended that a copy of the completed CMN or DIF be kept in the patient's record. However, neither a physician's order nor a CMN nor a DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient's medical record that supports the medical necessity for the item and ubstantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if applicable). Before submitting a claim to the DME MAC the supplier must have on file a dispensing order, the detailed written order, the CMN (if applicable), the DIF (if applicable), information from the treating physician concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation statements as defined in certain DME MAC policies. 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 ABN of possible denial has been obtained. Unless otherwise specified, the MAC, RAC and ZPIC/UPIC shall request information from the billing
provider/supplier. The treating physician, another clinician, provider, or supplier should submit the requested documentation. However, because the provider selected for review is the one whose payment is at risk, it is this provider who is ultimately responsible for submitting, within the established timelines, the documentation requested by the MAC, CERT, RAC and ZPIC/UPIC.". However, neither a physician's order nor a CMN nor a DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient's medical record that supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if applicable)". Also,"Before submitting a claim to the DME MAC the supplier must have on file a dispensing order, the detailed written order, the CMN (if applicable), the DIF (if applicable), information from the treating physician concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation statements as defined in certain DME MAC policies. 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 ABN of possible denial has been obtained. You can find this information in the edicare References: Medicare Program Integrity Manual Chapter 5 - Items and Services Having Special DME Review Considerations, Section 5.2 - Rules Concerning Orders, Subsection 5.2.1 - Physician Orders, Subsection 5.2.3 - Detailed Written Orders and Subsection 5.2.4 - Written Orders Prior to Delivery, Paragraph A. and Paragraph C. Medicare Program Integrity Manual, Chapter 5 - Items and Services Having Special DME Review Considerations, Section 5.8 - Supplier Documentation; Medicare Program Integrity Manual Chapter 4 - Program Integrity, Section 4.26 - Supplier Proof of Delivery Documentation Requirements, Subsection 4.26.1 - Proof of Delivery and Delivery Methods. Medicare Program Integrity Manual, Chapter 5 - Items and Services Having Special DME Review Considerations, Section 5.7 - Documentation in the Patient's Medical Record and Section 5.8 - Supplier Documentation; Medicare Program Integrity Manual, Chapter 3 - Verifying Potential Errors and Taking Corrective Actions, Section 3.2.3.3 - Third-Party Additional Documentation Request.
If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.