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.
Medicare guidance says "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 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 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." Lastly, "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 guidance in the 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 website www.medicareappeal.com.