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 Medicare plans must make reasonable and diligent efforts to gather and forward information 
to the Independent Review Entity (IRE). You can find this information in the Centers for Medicare and 
  
  Medicaid Services, Internet Only Manual, Parts C & D Enrollee Grievances, Organization/Coverage 
Determinations, and Appeals Grievance Manual, Section 50.12.1. 
The rules say that the reasonable useful lifetime for oxygen equipment is 5 years. The RUL is not based on the 
chronological age of the equipment. It starts on the initial date of service and runs for 5 years from that date. 
RUL also does not take into account exchanges of equipment, new suppliers, or changes of modality 
(concentrator, gaseous, liquid). 
Stationary and portable oxygen equipment is often provided at the same time therefore the RUL for both items 
run concurrently. When the RUL of a beneficiarys portable oxygen equipment differs from the RUL of the 
beneficiarys stationary oxygen equipment, the RUL of the stationary oxygen equipment shall govern the 
application of RUL-based rules and processes for both types, stationary and portable, of oxygen equipment. 
Until such time as the end date of the RUL of the stationary oxygen equipment is reached, the supplier must 
continue to furnish both the portable and stationary oxygen equipment. 
1. If the end date of the RUL of the portable oxygen equipment precedes the end date of the RUL of the 
stationary oxygen equipment, the end date of the RUL of the portable oxygen equipment is adjusted 
(extended) to coincide with the end date of the RUL of the stationary oxygen equipment. 
2. If the end date of the RUL of the portable oxygen equipment follows the end date of the RUL of the 
stationary oxygen equipment, the end date of the RUL of the portable oxygen equipment is adjusted 
(shortened) to coincide with the end date of the RUL of the stationary oxygen equipment. 
When the end date of the RUL of the stationary oxygen equipment occurs, the beneficiary may elect to obtain 
replacement of both the stationary and the portable oxygen equipment. 
If the beneficiary elects to obtain replacement of the stationary and the portable oxygen equipment, both types 
of oxygen equipment must be replaced at the same time. 
When the stationary and the portable oxygen equipment are replaced, a new 36-month rental period and new 
RUL is started for both the replacement stationary oxygen equipment and the replacement portable oxygen 
equipment. 
Beginning January 1, 2011, a beneficiary who resides in a DMEPOS competitive bidding area (CBA) may 
obtain replacement of both the stationary and portable oxygen systems only from a contract supplier having a 
competitive bidding contract for the CBA in which the beneficiary permanently resides. 
A grandfathered supplier for oxygen and other grandfathered equipment as of January 1, 2011, who has 
continued to furnish such equipment that has not yet reached the 36-month rental cap, does not qualify to 
furnish replacement equipment once the end date of the RUL of the stationary equipment is reached, if the 
beneficiary resides in the CBA when the end of the RUL has been reached, unless the status of the 
grandfathered supplier has changed to a contract supplier for the current round of the competitive bidding 
program. You can find these rules in the Oxygen and Oxygen Equipment - Policy Article A52514. 
 
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.