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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 state that for these items of DME, 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). 
 
For the first three rental months, the capped rental fee schedule is calculated so as to limit the monthly rental to 
10 percent of the average of allowed purchase prices 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. After paying the rental fee schedule amount for 15 months, no 
further payment may be made except for the 6-month maintenance and servicing fee (see 40.2).  
 
Effective May 1, 1991, suppliers must give beneficiaries the option of converting their capped rental equipment 
to purchased equipment during their 10th continuous rental month. DME MACs and A/B MACs (HHH) make 
no further rental payments after the 11th rental month for capped rental items until the supplier notifies the 
DME MAC or A/B MAC (HHH) that it has contacted the beneficiary and furnished him/her with the option of 
either purchase or continued rental. Information contained in Exhibit 1 may be furnished to beneficiaries by 
suppliers to help them make a rent/purchase decision. DME MACs and A/B MACs (HHH) provide copies of 
Exhibit 1 to suppliers. Beneficiaries have one month from the date the supplier makes the offer to accept this 
option. If the beneficiary declines or fails to respond to the purchase option, the A/B MAC (HHH) or DME 
MAC continues to make rental payments until the 15-month rental cap is reached. 
 
If the beneficiary accepts the purchase option, the DME MAC or A/B MAC (HHH) continues making rental 
payments until a total of 13 continuous rental months have been paid. The DME MAC or A/B MAC (HHH) 
will not make any additional rental payments beyond the 13th rental month. On the first day after 13 continuous rental months have been paid, the supplier must transfer title to the equipment to the beneficiary. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 20- Durable Medical Equipment, 
Prosthetics, Orthotics, and Supplies (DMEPOS) Sections 30.5, 30.5.1, 30.5.2. 
 
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.