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 MA plans may specify brands and manufacturers as preferred and charge lower cost-sharing 
for the preferred brands or may limit the Durable Medical Equipment (DME) to only those preferred brands 
and manufacturers, as long as the following conditions are met (42 CFR 422.100(l)): 
 
 The MA plan provides all categories of DME covered under original Medicare Part B; 
 The MA plan ensures that enrollees have access to all medically necessary (including non-preferred) DME 
products or brands; 
 The MA plans contracted suppliers provide access to all preferred DME brands; 
 During an enrollees first year of enrollment in an MA plan, if the enrollee requests, the plan will provide a 
90-day transition period (commencing with the initial time of enrollment) during which the plan provides (and 
repairs, as applicable) non-preferred DME brands furnished in the previous year; 
 Although the MA plan may add brands to its preferred formulary during the year, it may not remove any 
brands mid-year; 
 The MA plan treats denials of non-preferred DME products or brands as organization determinations; 
 The MA plan discloses DME coverage limitations and appeal rights in the case of a denial of a non-preferred 
DME product or brand with the Evidence of Coverage and Annual Notice of Change and on its website; and 
 The MA plan provides full coverage, without limitation on brand and manufacturer, to DME categories or 
subcategories annually determined by CMS to require full coverage. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS) Medicare Managed 
Care Manual Chapter 4, Section 10.12.2- Specifying Brands or Manufacturers of DME 
 
A decision that use of an air-fluidized bed is reasonable and necessary requires that: 
 
    The patient has a stage 3 (full thickness tissue loss) or stage 4 (deep tissue destruction) pressure sore; 
    The patient is bedridden or chair bound as a result of severely limited mobility; 
    In the absence of an air-fluidized bed, the patient would require institutionalization; 
    The air-fluidized bed is ordered in writing by the patient's attending physician based upon a comprehensive 
assessment and evaluation of the patient after completion of a course of conservative treatment designed to optimize conditions that promote wound healing. This course of treatment must have been at least one month in 
duration without progression toward wound healing. This month of prerequisite conservative treatment may 
include some period in an institution as long as there is documentation available to verify that the necessary 
conservative treatment has been rendered. 
    Use of wet-to-dry dressings for wound debridement, begun during the period of conservative treatment and 
which continue beyond 30 days, will not preclude coverage of air-fluidized bed. Should additional debridement 
again become necessary, while a patient is using an air-fluidized bed (after the first 30-day course of 
conservative treatment) that will not cause the air-fluidized bed to become non-covered. In all instances 
documentation verifying the continued need for the bed must be available. 
    A trained adult caregiver is available to assist the patient with activities of daily living, fluid balance, dry 
skin care, repositioning, recognition and management of altered mental status, dietary needs, prescribed 
treatments, and management and support of the air-fluidized bed system and its problems such as leakage; 
    A physician directs the home treatment regimen, and reevaluates and recertifies the need for the air-fluidized 
bed on a monthly basis; and 
    All other alternative equipment has been considered and ruled out. 
 
Home use of the air-fluidized bed is not covered under any of the following circumstances: 
 
    The patient has coexisting pulmonary disease (the lack of firm back support makes coughing ineffective and 
dry air inhalation thickens pulmonary secretions); 
    The patient requires treatment with wet soaks or moist wound dressings that are not protected with an 
impervious covering such as plastic wrap or other occlusive material; 
    The caregiver is unwilling or unable to provide the type of care required by the patient on an air-fluidized 
bed; 
    Structural support is inadequate to support the weight of the air-fluidized bed system (it generally weighs 
1600 pounds or more); 
    Electrical system is insufficient for the anticipated increase in energy consumption; or 
    Other known contraindications exist. 
 
You can find this information in the National Coverage Determination (NCD) Air-Fluidized Bed 280.8. 
 
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.