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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 A/B MACs (HHH) and DME MACs pay the fee schedule amounts on a monthly rental basis not 
to exceed a period of continuous use of 15 months. In the tenth month of rental, the beneficiary is given a 
purchase option (see 30.5.2). If the purchase option is exercised, A/B MACs (HHH) and DME MACs 
continue to pay rental fees not to exceed a period of continuous use of 13 months and ownership of the 
equipment passes to the beneficiary. If the purchase option is not exercised, A/B MACs (HHH) and DME 
MACs continue to pay rental fees until the 15-month cap is reached and ownership of the equipment remains 
with the supplier (see 30.5.4). In the case of electric wheelchairs only, the beneficiary must be given a 
purchase option at the time the equipment is first provided (see 30.5.3). 
 
Claims must specify whether equipment is rented or purchased. For purchased equipment, the itemized bill or 
claim must also indicate whether equipment is new or used. If the provider or supplier fails to indicate on an 
assigned claim whether equipment was new or used, the MAC processing the claims assumes purchased 
equipment is used and process the claim accordingly, i.e., they pay on the basis of the used purchase fee. If an 
unassigned purchase claim does not specify whether the item was new or used, MACs develop the claim with 
the supplier. 
 
 
 
 
 Items in this category are paid on a monthly rental basis not to exceed a period of continuous use of 13 months. 
Rental Fee Schedule -For the first three rental months, the monthly rental fee schedule is limited to 10 percent 
of the average allowed purchase price on assigned claims for new equipment during a base period, updated to 
account for inflation. For each of the remaining months, the monthly rental is limited to 7.5 percent of the 
average allowed purchase price. payment for power- driven wheelchairs furnished on or after January 1, 2011, 
is revised to pay 15 percent of the purchase price for the first three months under the monthly rental method 
and 6 percent for each of the remaining rental months 4 through 13. Modifiers used in this category are as 
follows: 
     a. RR Rental 
     b. KH First rental month 
     c. KI Second and third rental months 
     d. KJ Fourth to the thirteenth months 
 
You can find this rule in the Medicare Claims Processing Manual Chapter 20 - Durable Medical Equipment, 
Prosthetics, Orthotics, and Supplies (DMEPOS), 30.5 - Capped Rental Items and 130.9. 
 
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.