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 repairs to equipment which a beneficiary owns are covered when necessary to make the 
equipment serviceable. However, do not pay for repair of previously denied equipment or equipment in the 
frequent and substantial servicing or oxygen equipment payment categories. If the expense for repairs exceeds 
the estimated expense of purchasing or renting another item of equipment for the remaining period of medical 
need, no payment can be made for the amount of the excess. 
 
The rules say routine periodic servicing, such as testing, cleaning, regulating, and checking of the beneficiary's 
equipment, is not covered. The owner is expected to perform such routine maintenance rather than a retailer or 
some other person who charges the beneficiary. Normally, purchasers of DME are given operating manuals 
which describe the type of servicing an owner may perform to properly maintain the equipment. It is 
reasonable to expect that beneficiaries will perform this maintenance. Thus, hiring a third party to do such work 
is for the convenience of the beneficiary and is not covered. However, more extensive maintenance which, 
based on the manufacturers' recommendations, is to be performed by authorized technicians, is covered as 
repairs for medically necessary equipment which a beneficiary owns. This might include, for example, 
breaking down sealed components and performing tests which require specialized testing equipment not 
available to the beneficiary. 
  
The rules say replacement refers to the provision of an identical or nearly identical item. Situations involving the provision of a different item because of a change in medical condition are not addressed in this section. Equipment which the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood). A physician's order and/or new Certificate of Medical Necessity (CMN), when required, is needed to reaffirm the medical necessity of the item. Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot be identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful lifetime of the equipment. If the item of equipment has been in continuous use by the patient on either a rental or purchase basis for the equipment's useful lifetime, the beneficiary may elect to obtain a new piece of equipment. Replacement may be reimbursed when a new physician order and/or new CMN, when required, is needed to reaffirm the medical necessity of the item. The reasonable useful lifetime of durable medical equipment is determined through program instructions. In the absence of program instructions, the Plan may determine the reasonable useful lifetime of equipment, but in no case can it be less than 5 years. Computation of the useful lifetime is based on when the equipment is delivered to the beneficiary, not the age of the equipment. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment. During the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the beneficiary. You can find these rules in the Medicare Benefit Policy Manual, Chapter 15, 110.2 - Repairs, Replacement and Maintenance and Delivery.
 
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.