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 the rules state that equipment which the enrollee 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 physician's 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 enrollee on either a rental or purchase basis for the equipment's useful lifetime, the enrollee 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 (RUL) 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 enrollee, 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 enrollee. These rules can be found in the Medicare Benefit Policy Manual Chapter 15, Section 110.2 for Repairs, Maintenance, Replacement, and Delivery.  The rules say home oxygen therapy is reasonable and necessary only if all of the following conditions are met:      1. The treating practitioner has determined that the beneficiary has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy, and     2. The beneficiary's blood gas study meets the criteria stated below, and     3. The qualifying blood gas study was performed by a treating practitioner or by a qualified provider or supplier of laboratory services, and     4. The qualifying blood gas study was obtained under the following conditions:         If the qualifying blood gas study is performed during an inpatient hospital stay, the reported test must be the one obtained closest to, but no earlier than 2 days prior to the hospital discharge date, or         If the qualifying blood gas study is not performed during an inpatient hospital stay, the reported test must be performed while the beneficiary is in a chronic stable state - i.e., not during a period of acute illness or an exacerbation of their underlying disease, and     5. Alternative treatment measures have been tried or considered and deemed clinically ineffective.  You can find this information in Medicare's Local Coverage Determination (LCD): Oxygen and Oxygen Equipment (L33797).  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.