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 that all claims for Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) 
require a written order/prescription from the treating practitioner. The supplier must keep the order and proof of 
delivery documentation on file. All services that do not have appropriate proof of delivery will be denied. The 
supplier should also obtain as much documentation from the patients medical record as they determine they 
need to assure themselves that coverage criteria for an item have been met. If the information in the patients 
medical record does not adequately support the medical necessity for the item, the supplier is liable for the 
dollar amount involved unless a properly executed Advance Beneficiary Notice (ABN) of possible denial has 
been obtained. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only 
Manual, Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.1, 5.9 and 5.10. 
 
The rules say Method 2Delivery via Shipping or Delivery Service Directly to a Beneficiary  
 
If the supplier utilizes a shipping service or mail order, the proof of delivery (POD) documentation must be a 
complete record tracking the item(s) from the DMEPOS supplier to the beneficiary. An example of acceptable 
POD would include both the suppliers own detailed shipping invoice and the delivery services tracking 
information. The suppliers record must be linked to the delivery service record by some clear method like the 
delivery services package identification number or suppliers invoice number for the package sent to the 
beneficiary. The POD document must include: 
 
Beneficiarys name 
Delivery address 
Delivery services package identification number, supplier invoice number, or alternative method that links the 
suppliers delivery documents with the delivery services records 
A description of the item(s) being delivered. The description can be either a narrative description (e.g., 
lightweight wheelchair base), a HCPCS code, the long description of a HCPCS code, or a brand name/model 
number 
Quantity delivered 
Date delivered 
Evidence of delivery 
If a supplier utilizes a shipping service or mail order, suppliers have two options for the DOS to use on the 
claim: 
 
Suppliers may use the shipping date as the date of service (DOS). The shipping date is defined as the date the 
delivery/shipping service label is created or the date the item is retrieved by the shipping service for delivery. 
However, such dates should not demonstrate significant variation. 
Suppliers may use the date of delivery as the DOS on the claim.  
Suppliers may also utilize a return postage-paid delivery invoice from the beneficiary or designee as POD. This 
type of POD document must contain the information specified above. 
 
You can find this information in Medicare's Local Coverage Article: Standard Documentation Requirements 
for All Claims Submitted to DME MACs (A55426). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.