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 say reimbursement for oxygen equipment is limited to 36 monthly rental payments. Payment for 
accessories (e.g., cannula, tubing, etc.), delivery, back-up equipment, maintenance, and repairs is included in 
the rental allowance. Payment for oxygen contents (stationary and/or portable) is included in the allowance for 
stationary equipment (E0424, E0439, E1390, E1391). Payment for stationary equipment is increased for 
beneficiaries requiring greater than 4 liters per minute (LPM) of oxygen flow and decreased for beneficiaries 
requiring less than 1 LPM. If a beneficiary qualifies for additional payment for greater than 4 LPM of oxygen 
and also meets the requirements for portable oxygen, the appropriate modifiers (QB or QF) must be used. 
 
A new 36-month rental period can begin only in the following situations: 
 
      Specific incident of damage beyond repair (e.g., dropped and broken, fire, flood, etc.) or the item is stolen 
or lost 
      Break-in-need for at least 60 days plus the days remaining in the month of discontinuation and new 
medical necessity is established (see BREAK-IN-SERVICE below) 
 
A new 36-month rental period does not start in the following situations: 
 
      Replacing equipment due to malfunction, wear and tear, routine maintenance, repair 
      Providing different equipment based on a treating practitioner order or beneficiary request for an upgrade 
      Break-in-need less than 60 days plus the days remaining in the month of discontinuation (see BREAK-
IN-SERVICE below) 
      Break-in-billing (see BREAK-IN-SERVICE below) 
      Changing suppliers 
 
There is no further payment for oxygen equipment during the 5-year reasonable useful lifetime (RUL) of the 
equipment after 36 rental payments have been made. If use of portable equipment (E0431, E0433, E0434, 
E1392, K0738) begins after the use of stationary equipment begins, payment for the portable equipment can 
continue after payment for the stationary equipment ends until 36 rental payments have been made for the 
portable equipment. For information on payment for contents and maintenance, see separate sections below. 
The supplier who provided the equipment during the 36th rental month is required to continue to provide the 
equipment, accessories, contents (if applicable), maintenance, and repair of the oxygen equipment during the 5-
year reasonable useful lifetime of the equipment. Rules for providing different equipment/modalities are the 
same in months 37-60 as they are in the initial 36 months (see above). A new 36-month rental period can begin only in the following situation: 
 
      There is a specific incident of damage beyond repair (e.g., dropped and broken, fire, flood, etc.) or the item 
is stolen or lost 
 
A new 36-month rental period does not start in the following situations: 
 
      Replacing equipment due to malfunction, wear and tear, routine maintenance, repair 
      Providing different equipment based on a treating practitioner order or beneficiary request for an upgrade 
      Break-in-need (see BREAK-IN-SERVICE below) 
      Break-in-billing (see BREAK-IN-SERVICE below) 
      Changing suppliers 
 
You can find this information in the Local Coverage Article: Oxygen and Oxygen Equipment A52514. 
 
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.