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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 say that providers/suppliers must report services correctly. Procedures should be reported with the
Current Procedural Terminology (CPT) code that describes the services performed. You can find this rule in
the Centers for Medicare and Medicaid Services, Medicare National Correct Coding Initiative Policy Manual
for Medicare Services, Chapter I(A).
The rules say that during the rental of a Transcutaneous Electrical Never Stimulators (TENS) unit, supplies for
the unit are included in the rental allowance; there is no additional allowance for items such as electrodes, lead
wires, and batteries. If a TENS unit (E0720 or E0730) is purchased, the allowance is all-inclusive of items such
as lead wires and one month's supply of items such as electrodes, conductive paste or gel (if needed), and
batteries. You can find this in the Medicare Local Coverage Article (LCA) Transcutaneous Electrical Never
Stimulators (TENS) Policy Article A52520.
The rules say that separate allowance will be made for replacement supplies when they are reasonable and
necessary and are used with a covered TENS. Usual maximum utilization is:
- 2 TENS leads - a maximum of one unit of A4595 per month.
- 4 TENS leads - a maximum of two units of A4595 per month.
If the use of the TENS unit is less than daily, the frequency of billing for the TENS supply code should be
reduced proportionally. For items and supplies provided on a recurring basis, billing must be based on
prospective, not retrospective use. For products that are supplied as refills to the original order, suppliers must
contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-determined basis, even
if authorized by the beneficiary. This shall be done to ensure that the refilled item remains reasonable and
necessary, existing supplies are approaching exhaustion, and to confirm any changes or modifications to the
order. Contact with the beneficiary or designee regarding refills must take place no sooner than 14 calendar
days prior to the delivery/shipping date. For delivery of refills, the supplier must deliver the supplies no sooner
than 10 calendar days prior to the end of usage for the current product.
This is regardless of which delivery method is utilized. For all items that are provided on a recurring basis,
suppliers are required to have contact with the beneficiary or caregiver/designee prior to dispensing a new
supply of items. Suppliers must not deliver refills without a refill request from a beneficiary. Items delivered
without a valid, documented refill request will be denied as not reasonable and necessary. Suppliers must not
dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to
changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the treating
practitioners that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not
dispense more than a three (3) - month quantity at a time. You can find this in the Medicare Local Coverage
Determination (LCD) Transcutaneous Electrical Nerve Stimulators (TENS) L33802.
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.