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 Routine periodic servicing, such as testing, cleaning, regulating, and checking of the 
beneficiary's equipment, is not covered. The owner is expected to perform such routine maintenance rather 
than a retailer or some other person who charges the beneficiary. Normally, purchasers of DME are given 
operating manuals which describe the type of servicing an owner may perform to properly maintain the 
equipment.  It is reasonable to expect that beneficiaries will perform this maintenance.  Thus, hiring a third 
party to do such work is for the convenience of the beneficiary and is not covered. However, more extensive 
maintenance which, based on the manufacturers recommendations, is to be performed by authorized 
technicians, is covered as repairs for medically necessary equipment which a beneficiary owns. This might 
include, for example, breaking down sealed components and performing tests which require specialized testing 
equipment not available to the beneficiary. Do not pay for maintenance of purchased items that require frequent 
and substantial servicing or oxygen equipment. Since renters of equipment recover from the rental charge the 
expenses they incur in maintaining in working order the equipment they rent out, separately itemized charges 
for maintenance of rented equipment are generally not covered. Payment may not be made for maintenance of 
rented equipment other than the maintenance and servicing fee established for capped rental items. For capped 
rental items which have reached the 15-month rental cap, contractors pay claims for maintenance and servicing 
fees after 6 months have passed from the end of the final paid rental month or from the end of the period the 
item is no longer covered under the supplier's or manufacturer's warranty, whichever is later. See the Medicare 
Claims Processing Manual, Chapter 20, Durable Medical Equipment, Prosthetics and Orthotics, and Supplies 
(DMEPOS), for additional instruction and an example. You can find this information in Medicare's CMS 
Manual System Pub. 100-02 Medicare Benefit Policy. 
 
The rules say that 1. Payment may be made for following: (b) Separate charges for repair, maintenance and 
delivery: Repairs -only if DME is being purchased or is already owned by patient and repair is necessary to 
make the equipment serviceable.  Medicare pays the least expensive alternative. (See special exception in 
Chapter 15 of the Medicare Benefit Policy Manual for repair of dialysis delivery system.) NOTE: See Chapter 
15 of the Medicare Benefit Policy Manual for handling claims suggesting deliberate or malicious damage or 
destruction. Maintenance - only if the equipment is being purchased, or is already owned by the patient, and if 
the maintenance is extensive amounting to repairs, i.e., requiring the services of skilled technicians. (MACs 
deny claims for routine maintenance and periodic servicing, e.g., testing, cleaning, checking, oiling, etc.)  (See 
special exception in Chapter 15 of the Medicare Benefit Policy Manual for maintenance of dialysis delivery 
system.) Delivery - of rented or purchased equipment is covered, but the related payment is included in the fee 
schedule for the item.  Additional payment may be made at the discretion of the MAC in special circumstances 
(see Chapter 15  of the Medicare Benefit Policy Manual). 
 
You can find this information in the Medicare Claims Processing Manual Chapter 20 - Durable Medical 
Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.