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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 during the rental of a Transcutaneous Electrical Nerve 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 rule in the Local Coverage Article (LCA) Transcutaneous Electrical Nerve
Stimulators (TENS) - Policy Article (A52520).
The rules say that for durable medical equipment 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 predetermined
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
DMEPOS product 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 rule in the Medicare Local Coverage
Determination (LCD) Transcutaneous Electrical Nerve Stimulators (TENS) (L33802).
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).
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.