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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 Code of Federal Regulations (CFR) Section 422.101.
The rules state that equipment which the enrollee owns or is a capped rental item may be replaced in cases of
loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire,
flood). A physician's order and/or new Certificate of Medical Necessity (CMN), when required, is needed to
reaffirm the medical necessity of the item.
Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot
be identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful
lifetime of the equipment. If the item of equipment has been in continuous use by the enrollee on either a rental
or purchase basis for the equipment's useful lifetime, the enrollee may elect to obtain a new piece of
equipment. Replacement may be reimbursed when a new physician order and/or new CMN, when required, is
needed to reaffirm the medical necessity of the item.
The reasonable useful lifetime of durable medical equipment is determined through program instructions. In the
absence of program instructions, A/B MACS (B) may determine the reasonable useful lifetime (RUL) of
equipment, but in no case can it be less than 5 years. Computation of the useful lifetime is based on when the
equipment is delivered to the enrollee, not the age of the equipment. Replacement due to wear is not covered
during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does
cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment
owned by the enrollee. These rules can be found in the Medicare Benefit Policy Manual Chapter 15, Section
110.2 for Repairs, Maintenance, Replacement, and Delivery.
Medicare guidance says "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 website www.medicareappeal.com.