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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 coverage and payment for Medicare telehealth services includes consultation, office visits,
individual psychotherapy, and pharmacologic management delivered via a telecommunications system.
Eligible geographic areas include rural health professional shortage areas (HPSA) and counties not classified as
a metropolitan statistical area (MSA). The originating site for telehealth services (location to which the enrollee
presents) must be a practitioner's office, hospital, rural health clinic (RHC), federally qualified health center
(FQHC), skilled nursing facility or community mental health center. You can find this rule in the Centers for
Medicare and Medicaid Services, Internet Only Manual, Medicare Claims Processing Manual, Chapter 12,
Sections 190.1 and 190.2.
The rules say that for eligible telehealth services, telecommunications systems substitute for an in-person
encounter. Medicare enrollees are eligible for telehealth services only if they are presented from an originating
site located in either a county outside of a Metropolitan Statistical Area (MSA) or a rural Health Professional
Shortage Area (HPSA) located in a rural census tract. You can find this in the CMS MLN document entitled
"Telehealth Services."
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. 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 at
Medicare Program Integrity Manual Chapter 5, Section 5.8.
The contractor shall verify that the face-to-face encounter documentation includes information supporting that
the beneficiary was evaluated or treated for a condition that supports the DME item(s) ordered. If this
information is not included, the contractor shall deny the claim. If the physician completed the written order
before the face-to-face encounter, the contractor shall deny the claim. You can find these rules in the Medicare Program Integrity Manual, Chapter 5 - Items and Services Having
Special DME Review Considerations Section 5.2.5.1 - Face-to-Face Encounter.
Knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a beneficiary who is
ambulatory and has knee instability due to a condition specified in the Group 4 ICD-10 Codes in the LCDrelated
Policy Article.
A knee orthosis, Swedish type, prefabricated (L1850) is covered for a beneficiary who is ambulatory and has
knee instability due to genu recurvatum - hyperextended knee, congenital or acquired (refer to the Group 5
ICD-10 Codes in the LCD-related Policy Article).
For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by
examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability,
anterior/posterior Drawer test).
Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and
necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied
if only pain or a subjective description of joint instability is documented. You can find this information in the
Local Coverage Determination (LCD): KNEE Orthoses (L33318).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.