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. 
 
The rules state that to repair means to fix or mend and to put the equipment back in good condition after 
damage or wear. Repairs to equipment which a beneficiary owns are covered when necessary to make the 
equipment serviceable. However, do not pay for repair of previously denied equipment or equipment in the 
frequent and substantial servicing or oxygen equipment payment categories. If the expense for repairs exceeds 
the estimated expense of purchasing or renting another item of equipment for the remaining period of medical 
need, no payment can be made for the amount of the excess. (See subsection C where claims for repairs suggest 
malicious damage or culpable neglect.) Since renters of equipment recover from the rental charge the expenses, 
they incur in maintaining in working order the equipment they rent out, separately itemized charges for repair 
of rented equipment are not covered. This includes items in the frequent and substantial servicing, oxygen 
equipment, capped rental, and inexpensive or routinely purchased payment categories which are being rented. 
 
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 physicians 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 equipments 
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.) Charges for the replacement of oxygen equipment, 
items that require frequent and substantial servicing or inexpensive or routinely purchased items which are 
being rented are not covered. Cases suggesting malicious damage, culpable neglect, or wrongful disposition of 
equipment should be investigated and denied where the DME MACs determines that it is unreasonable to make 
program payment under the circumstances. DME MACs refer such cases to the program integrity specialist in the RO. 
 
You can find this information in the Medicare Benefit Policy Manual Chapter 15  110.2 - Repairs, 
Maintenance, Replacement, and Delivery. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.