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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 medically necessary services are those that are reasonable and necessary for the diagnosis or treatment of an illness or injury. Medically necessary services include services to improve the functioning of a malformed body member. You can find this rule in the Social Security Act, Section 1862(a)(1)(A).  The rules say that services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. You can find this rule at 42 CFR Sections 411.15 and 411.15(o).  The rules say that there are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file SWO, a WOPD (if applicable), a CMN (if applicable), a DIF (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation statements as defined in certain DME MAC policies. The supplier should also obtain as much documentation from the patient's medical record in order to assure themselves that coverage criteria for an item have been met. If the information in the patient's medical record does not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved unless a properly executed Advance Beneficiary Notice of Noncoverage (ABN) of possible denial has been obtained. CMS requires that in the event of an audit, the MACs, CERT, SMRC, Recovery Auditors, and UPICs shall determine that an item/service is correctly coded. The supplier must have on file a description of items provided to the beneficiary in sufficient detail to determine the accuracy of claims coding including a description of the items(s) delivered. The description can be either a narrative description (e.g., lightweight wheelchair base), a HCPCS code, the long description of a HCPCS code, or a brand name/model number. Reimbursement shall be based on the specific utilization amount that is supported by contemporaneous medical records. Documentation must be maintained in the supplier's files for seven (7) years from DOS.  If the Medicare qualifying supplier documentation is older than 7 years, proof of continued medical necessity of the item or necessity of the repair can be used as the supporting Medicare qualifying documentation. REASONABLE AND NECESSARY CRITERIA (R&N) CMS National Coverage Determinations (NCDs) and contractor Local Coverage Determinations (LCDs) describe the requirements that must be met for an item to be considered R&N. These R&N criteria are often referred to as medical necessity. MEDICAL RECORD DOCUMENTATION In the event of a claim review, information contained directly in the contemporaneous medical record is the source required to justify payment except as noted elsewhere for prescriptions and CMNs. The medical record is not limited to treating practitioner's office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all-inclusive). Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for determining that an item is reasonable and necessary. DMEPOS suppliers are reminded that:      Supplier-produced records, even if signed by the treating practitioner, and attestation letters (e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes.     Templates and forms, including CMS CMNs, are subject to corroboration with information in the medical record.     A prescription is not considered to be part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record.  In addition to the general requirements discussed above, certain DMEPOS items may have specific documentation requirements. Details regarding these policy specific requirements are contained in the applicable LCD-related Policy Article. CONTINUED MEDICAL NEED For all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered; therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription. For purchased items, initial months of a rental item or for initial months of ongoing supplies or drugs, information justifying reimbursement will come from this timeframe. Entries in the beneficiary's medical record must have been created prior to, or at the time of, the initial DOS to establish whether the initial reimbursement was justified based upon the applicable coverage policy. For ongoing supplies and rented DME items, in addition to information described above that justifies the initial provision of the item(s) and/or supplies, there must be information in the beneficiary's medical record to support that the item continues to remain reasonable and necessary. Information used to justify continued medical need must be timely for the DOS under review. Any of the following may serve as documentation justifying continued medical need:      A recent order/prescription by the treating practitioner for refills;     A recent change in an order/prescription;     A properly completed CMN or DIF with an appropriate length of need specified;     Timely documentation in the beneficiary's medical record showing usage of the item.  Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy.  You can find this information in Medicare's  Local Coverage Article Standard Documentation Requirements for All Claims Submitted to DME MACs A55426.  If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.