The following clarifications are designed to assist suppliers who wish to appeal original claim denials through the appeals process. Original claim denials are often upheld at the redetermination or reconsideration level of appeal due to the lack of documentation supporting the medical necessity of services rendered.

Before requesting a redetermination or reconsideration, consult the Jurisdiction B DME MAC Supplier Manual, supplier bulletins and all applicable medical policy and documentation guidelines for each piece of equipment/supply being appealed. Failure to include all appropriate documentation with the appeal may result in an unfavorable decision.

The appellant has the responsibility to provide information and/or documentation for supplier submitted appeals. Decisions at these levels are based exclusively on the information and/or documentation submitted with the case.

The examples below describe common denial situations presented through the appeals process:

1. Medical necessity of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items. Medical necessity is established by copies of medical records that address the condition of the patient and how the item in question fits into the treatment plan of the patient. Depending on the item in question, the documentation would include, for example, some of the following information:

• The diagnosis relating to the limitations and or relating to the need for the equipment/supply
• Complicating medical conditions
• Functional abilities (e.g., ability to ambulate or transfer, the distance that the patient can walk independently and/or with the assistance of a walker or other ambulatory aid, or abilities of the upper and lower extremities [including tone, range of motion limitations, etc.])
• Amount of time in bed, chair, or wheelchair
• Frequency and type of activities outside the home
• Functional limitation
• Rehabilitation potential (including recent prior functional level)
• Duration of the condition
• Description of and response to prior treatment experience with other equipment prognosis
• Physical examination findings, test results, etc.
• Certificate of Medical Necessity (CMN) or DME Information Form (DIF) if required

Note: if a patient can bear weight to transfer from a bed to a chair or wheelchair, the patient is considered nonambulatory.

2. Individual consideration pricing determinations.

• Item—the brand name and model name/number should be given and copies of the invoice and/or catalogue with prices should be included.
• Custom made item—include a detailed description and/or photograph.
• Service (e.g., repair, custom item)—list the labor time and the major materials used and their cost.

In addition to the documentation types described above, copies of the doctor’s orders or narrative explanations by the supplier/physician may assist in clarifying the medical necessity of items/services provided. Handwritten documentation must be legible to be effective in the appeal process.

3. Same or similar equipment. It is the responsibility of the beneficiary and supplier to coordinate with all the involved parties to ensure that equipment is only provided when it is medically necessary and to determine the equipment provided the patient is not a duplication of previously obtained equipment.

Note: The following guidelines pertain to claim submission to the Jurisdiction B DME MAC.

If a supplier is billing for a new capped rental period, the code must have modifier KH and an initial CMN or DIF must accompany the claim if a CMN or DIF is required for the code. When the DME MAC receives a claim for a capped rental code that has been previously approved and there has been any interruption of billing to the DME MAC, the presumption is that there has been no interruption in medical necessity for the item—unless it is clearly documented. Therefore, if there is a 60-plus day interruption of billing for a capped rental code (whether or not that code requires a CMN or DIF), and the supplier thinks that starting a new capped rental period is justifiable, narrative documentation must accompany the claim. The documentation must include, but is not limited to:

1. Pick up slip from other supplier(s)
2. Delivery slip from current supplier (Note: If pick up and delivery slips are not submitted,
Medicare will continue to allow payment to the other supplier.)
3. Description of the patient’s prior medical condition which necessitated the previous item
4. Statement explaining when and why the medical necessity for the previous item ended
5. Statement explaining the patient’s new or changed medical condition and when the new need began. This information must be entered in the note (NTE) segment of an electronic claim or attached to a paper claim.

Though suppliers should always try to determine whether a beneficiary has had the same or related equipment before, there are situations in which a supplier may submit an initial claim for a capped rental item not knowing that another supplier has previously been approved for the same or related code. Since in this situation additional narrative documentation justifying the start of a new capped rental period will not have been sent with the claim, the DME MAC will presume that there has been no substantial change in the medical necessity for the item.

If coverage criteria for the item are met, the code will be approved, but the modifier will be changed from a KH to a KI or KJ as appropriate to indicate that it is being processed and paid as a continuation of a previous capped rental situation. If the new supplier disagrees with this determination, they can obtain the information described above and submit the claim as an appeal.