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: 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 noncompliance
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 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 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 guidance says, The following modifiers were added to the
HCPCS to identify supplies and equipment that may be covered under more than one DMEPOS benefit
category: - AU Item furnished in conjunction with a urological, ostomy, or tracheostomy supply; - AV Item
furnished in conjunction with a prosthetic device, prosthetic or orthotic; and - AW Item furnished in
conjunction with a surgical dressing. Codes A4450 and A4452 are the only codes that have been identified at
this time that would require use of all three of the above listed modifiers. Providers must report these modifiers
on claims for items identified by codes A4450 and A4452 that are furnished on or after January 1, 2005.
Modifier AU may also be applicable to code A4217. Providers must report modifier AU on claims for items
identified by code A4217 that are furnished in conjunction with a urological, ostomy, or tracheostomy supply
on or after January 1, 2005. Items identified by code A4217 that are furnished in conjunction with durable
medical equipment are reported without a modifier. In the future, other codes may be identified as codes that
must be submitted with these modifiers. Medicare contractors base payment for the codes A4217, A4450, and
A4452 on the presence or absence of these modifiers. You can find this guidance in the Medicare Claims
Processing Manual Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS),
Section 30.9 - Payment of DMEPOS Items Based on Modifiers.
Medicare guidance says, Modifiers "AV" and "AU" are being added to HCPCS code A5120 for billing items
furnished in conjunction with facial prosthetics and urological supplies, respectively. You can find this
guidance in the CMS Manual System Change Request 4194.
Medicare guidance says, HCPCS A4452; Mod- AU, AV and AW. HCPCS A5120; Mod- AU and AV. You can
find this guidance in the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) July
2019 Fee Schedule.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.