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 a Standard Written Order (SWO) must be communicated to the supplier before a claim is 
submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, 
the claim shall be denied as not reasonable and necessary. 
 
For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a 
Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS 
item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the 
claim shall be denied as not reasonable and necessary.  
 
For DMEPOS base items that require a WOPD, and also require separately billed associated options, 
accessories, and/or supplies, the supplier must have received a WOPD which lists the base item, and which 
may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of 
the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies 
without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be 
denied as not reasonable and necessary. 
 
An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, 
LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be 
denied as not reasonable and necessary/incorrectly coded. 
 
For DMEPOS items and supplies provided on a recurring basis, billing must be based on prospective, not 
retrospective use. For DMEPOS 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 pre-determined 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 DMEPOS 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 one (1) month supply at a time for a 
beneficiary in a nursing facility and a three (3) month supply for a beneficiary at home. 
 
You can find this rule in the Local Coverage Determination (LCD) L33828. 
 
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.