(Medicare Benefit Policy Manual)

 Meets at least the basic requirement (see 1819(a)(1) of the Act) in the definition of a skilled nursing facility, i.e., it is primarily engaged in providing to inpatients skilled nursing care and related services for patients who require medical or nursin g care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons.   Thus, if an individual is a patient in an institution or distinct part of an institution which provides the services described in the bullets above, the individual is not entitled to have separate Part B payment made for rental or purchase of DME.  This is  because such an institution may not be considered the individuals home (see 1861(s)(6) and 1861(n) of the Act, the implementing regulations at 42 CFR 410.38(b), and 2160B in the State Operations Manual (SOM, Pub. 100- 07), Chapter 2).   As indicated in 2164 of the SOM, Chapter 2, all hospitals and SNFs that are Medicare- certified are automatically considered to meet the basic requirement described in the applicable bullet above by reason of the Medicare certification itself.  Moreover, even an institution (or portion of an institution) that is not certified for Medicare is precluded from being considered a patients home in this context if it meets either of these basic requirements.  See 2166 of the SOM, Chapter 2, for the administrativ e criteria used in determining whether the basic requirement in the SNF definition is met by a nursing home that is not Medicare-certified (including the non-Medicare portion of an institution that also contains a Medicare-certified distinct part SNF).   If the patient is at home for part of a month and, for part of the same month is in an institution that cannot qualify as his or her home, or is outside the U.S., monthly payments may be made for the entire month.  Similarly, if DME is returned to the prov ider before the end of a payment month because the beneficiary died in that month or because the equipment became unnecessary in that month, payment may be made for the entire month.  110.2 - Repairs, Maintenance, Replacement, and Delivery  (Rev. 203, Issued: 02-13-15, Effective: 07-01-15, Implementation: 07-06-15)  Under the circumstances specified below, payment may be made for repair, maintenance, and replacement of medically required DME, including equipment which had been in use before the user enrolled in Part B of the program.  However, do not pay for repair, maintenance, or replacement of equipment in the frequent and substantial servicing or oxygen equipment payment categories.  In addition, payments for repair and maintenance may not include payment for parts and labor covered under a manufacturers or suppli ers warranty.   A.  Repairs   To repair means to fix or mend and to put the equipment back in good condition after damage or wear.  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.  (See subsection C where claims for repairs suggest malicious damage or culpable neglect.)  Since renters of equipment recover from the rental charge the expenses they incur in maintaining in working order the equipment they rent out, separately itemized charges for repair of rented equipment are not covered.  This includes items in the frequent and substantial servicing, oxygen equipment, capped rental, and inexpensive or routinely purchased payment categories which are being rented.  A new Certificate of Medical Necessity (CMN) and/or physicians order is not needed for repairs.  For replacement items, see Subsection C below.   B.  Maintenance  Routine periodic servicing, such as testing, cleaning, regulating, and checking of the beneficiarys 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.  Do not pay for maintenance of purchased items that require frequent and substantial servicing or oxygen equipment.  Since renters of equipment recover from the rental charge the expenses they incur in maintaining in working order the equipment they rent out, separately itemized charges for maintenance of rented equipment are generally not covered.  Payment may not be made for maintenance of rented equipment other than the maintenance and servicing fee established for capped rental items.  For  capped rental  items  which  have  reached  the 13-month rental  cap,  contractors  pay claims  for maintenance and servicing  fees after  6 months  have  passed  from  the end of the final  paid  rental  month or  from  the end of the period the  item is  no longer  covered  under  the suppliers  or manufacturers  warranty,  whichever  is later.  See the Medicare Claims Processing Manual, Chapter 20, Durable Medical Equipment, Prosthetics and Orthotics, and Supplies (DMEPOS), for additional instruction and an example.  A new CMN and/or physicians order is not needed for covered maintenance.  In cases where one or more monthly rental payments have been made in accordance with 42 CFR 414.229 for a capped rental DME item, medical necessity for the equipment has been established.  In cases where one or more rental payments have been made for an item classified as capped rental DME, and the supplier transfers title to the equipment prior to the end of a 13 month period of continuous use per 42 CFR 414.230 , Medicare payment can be made for reasonable and necessary maintenance and servicing of the beneficiary -owned DME.  Under the regulations at 42 CFR 414.210(e)(1) , reasonable and necessary charges for maintenance and servicing are those made for parts and labor not otherwise covered under a manufacturers or suppliers warranty.  Charges for routine maintenance and servicing would not be covered.  Charges for maintenance and servicing that exceed the purchase price of the equipment (i.e., the capped rental monthly fee multiplied by 10) would not be reasonable and necessary and should be denied.  C.  Replacement   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 physicians 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 equipments 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, A/B MACS (B) 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 us eful lifetime, Medicare does cover repair up to the cost of replacement (but not actual replacement) for medically necessary equipment owned by the beneficiary. (See subsection A.)  Charges for the replacement of oxygen equipment, items that require frequent and substantial servicing or inexpensive or routinely purchased items which are being rented are not covered.  Cases suggesting malicious damage, culpable neglect, or wrongful disposition of equipment should be investigated and denied where the DME MACs determines that it is unreasonable to make program payment under the circumstances.  DME MACs refer such cases to  the program integrity specialist in the RO.   D.  Delivery   Payment for delivery of DME whether rented or purchased is generally included in the fee schedule allowance for the item.  See Pub. 100- 04, Medicare Claims Processing Manual, Chapter 20, Durable Medical Equipment, Prosthetics and Orthotics, and Supplies ( DMEPOS), for the rules that apply to making reimbursement for exceptional cases.   110.3 - Coverage of Supplies and Accessories  (Rev. 1, 10- 01-03) B3-2100.5, A3- 3113.4, HO -235.4, HHA -220.5  Payment may be made for supplies, e.g., oxygen, that are necessary for the effective use of durable medical equipment.  Such supplies include those drugs and biologicals which must be put directly into the equipment in order to achieve the therapeutic bene fit of the durable medical equipment or to assure the proper functioning of the equipment, e.g., tumor chemotherapy agents used with an infusion pump or heparin used with a home dialysis system.  However, the coverage of such drugs or biologicals does not preclude the need for a determination that the drug or biological itself is reasonable and necessary for treatment of the illness or injury or to improve the functioning of a malformed body member.   In the case of prescription drugs, other than oxygen, used in conjunction with durable medical equipment, prosthetic, orthotics, and supplies (DMEPOS) or prosthetic devices, the entity that dispenses the drug must furnish it directly to the patient for whom a prescription is written.  The entity that dispenses the drugs must have a Medicare supplier number, must possess a current license to dispense prescription drugs in the State in which the drug is dispensed, and must bill and receive payment in its own name.  A supplier that is not the entity that dispenses the drugs cannot purchase the drugs used in conjunction with DME for resale to the beneficiary.  Reimbursement may be made for replacement of essential accessories such as hoses, tubes, mouthpieces, e tc., for necessary DME, only if the beneficiary owns or is purchasing the equipment.   110.4 - Miscellaneous Issues Included in the Coverage of Equipment  (Rev. 1, 10- 01-03) B3-2100.6, A3- 3113.5, HO -235.5, HHA -220.6  Payment can be made for the purchase of DME even though rental payments may have been made for prior months.  This could occur where, because of a change in his/her condition, the beneficiary feels that it would be to his/her advantage to purchase the equipment rather than to continue to rent it.  A beneficiary may sell or otherwise dispose of equipment for which they have no further use, for example, because of recovery from the illness or injury that gave rise to the need for the equipment. (There is no authority for the program to repossess the e quipment.)  If after such disposal there is again medical need for similar equipment, payment can be made for the rental or purchase of that equipment.  However, where an arrangement is motivated solely by a desire to create artificial expenses to be met by the program and to realize a profit thereby, such expenses would not be covered under the program.  The resolution of questions involving the dispositi on and subsequent acquisition of durable medical equipment must be made on a case- by-case basis.   Cases where it appears that there has been an attempt to create an artificial expense and realize a profit thereby should be developed and when appropriate denied.  After adjudication the DME MAC would refer such cases to the program integrity specialist in the RO.  When payments stop because the beneficiarys condition has changed and the equipment is no longer medically necessary, the beneficiary is responsible for the remaining noncovered charges.  Similarly, when payments stop because the beneficiary dies, the ben eficiarys estate is responsible for the remaining noncovered charges.   Contractors do not get involved in issues relating to ownership or title of property.  110.5 - Incurred Expense Dates for Durable Medical Equipment  (Rev. 1, 10- 01-03) A3-3113.7.B, HO -235.7.B, B3- 3011  The date of service on the claim must be the date that the beneficiary or authorized representative received the DMEPOS item.  If the date of delivery is not specified on the bill, the contractor should assume, in the absence of evidence to the contrary, t hat the date of purchase was the date of delivery.   For mail order DMEPOS items, the date of service on the claim must be the shipping date.  The date of service on the claim must be the date that the DMEPOS item(s) was received by the nursing facility if the supplier delivered it or the shipping date if the supplier utilized a delivery/shipping service.