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 "Replacement refers to the provision of an identical or nearly identical item. Situations
involving the provision of a different item because of a change in medical condition are not addressed in this
section. Equipment which the beneficiary 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 patient on either a rental or purchase basis for the equipment's useful lifetime, the beneficiary 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 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
beneficiary, 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 beneficiary. (See
subsection A.)." For Medicare to consider coverage and payment for any item or service, the information
submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical
documentation and confirm that Medicare coverage criteria have been met. Physicians must report services
correctly. This manual discusses general coding principles in Chapter I and principles more relevant to other
specific groups of HCPCS/CPT codes in the other chapters. There are certain types of improper coding that
physicians must avoid. Procedures should be reported with the most comprehensive CPT code that describes
the services performed. Physicians must avoid upcoding. A HCPCS/CPT code may be reported only if all
services described by that code have been performed." 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; and 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.