Tuesday, April 23, 2019

Quality to the Next Level


Use Compatibility Mode
in Internet Explorer 9 or higher

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)

Minimize
1-1322122613 - Friday, November 1, 2013

Rationale for the Referral:  The ALJ erred in waiving recoupment of an overpayment under §§ 1879 and 1870 of the Act on the basis that the supplier-appellant’s review of Medicare’s Common Working File on the date of service constitutes reasonable care in billing for, and accepting, payment.

Referral Document

Appeals Council Decision

 
1-857871118 - Friday, May 10, 2013

Rationale for the Referral:  Section 1870 of the Social Security Act addresses waiver of recoupment of overpayments. Section 1870 does not apply in a case where the claim was denied initially and no overpayment occurred. Since the ALJ found the services were not reasonable and necessary, an analysis as to whether the Appellant is entitled to a waiver of liability under § 1879 of the Act is necessary. Criteria for determining whether the supplier could reasonably have been expected to that the services would not be covered under § 1879 do not allow waiver of recoupment or liability on the basis that the DME supplier relied on the physician’s order and progress in furnishing the amount it billed to Medicare.

Referral Document

Appeals Council Decision

 
1-1097802958 - Monday, May 6, 2013
Rationale for the Referral: The ALJ erred in allowing coverage for the power seat elevation system without considering whether E2300 meets the regulatory definition of DME and without affording deference to well-established CMS and contractor policies.

Referral Document

Appeals Council Decision

 
1-943773510 - Monday, April 1, 2013
Rationale for the Referral: For a pneumatic compressor device (PCD) to be covered, National Coverage Determination (NCD) 280.6 and the applicable contractor Local Coverage Determination (LCD) require a beneficiary to undergo a four-week trial of conservative therapy and an evaluation and determination by the treating physician's that there has been no significant improvement or that significant symptoms remain after the trial.

Referral Document

Appeals Council Decision

 
1-944263974 - Monday, April 1, 2013
Rationale for the Referral: Medicare does not cover a power seat elevation system (Healthcare Common Procedure Coding System (HCPCS) code E2300) furnished as a power wheelchair accessory because it is not primarily used to serve a medical purpose and thus does not meet the definition of DME.

Referral Document

Appeals Council Decision

 
1-771278529 - Tuesday, June 5, 2012

Rationale for the Referral: 1. A face-to-face assessment report conducted and signed by a physical therapist does not constitute a valid face-to-face examination report for purposes of determining coverage for a power wheelchair under 42 C.F.R. § 410.38(c) and contractor local coverage determination (LCD) L23613. 2. Applicable contractor LCD and policy article indicate E2300 (power seat elevation system) is not covered because it is not primarily medical in nature and thus does not meet the definition of durable medical equipment (DME). 3) An ALJ may not add claims to a pending appeal unless the new claim has first received an initial determination, redetemination and reconsideration. See 42 C.F.R. § 405.1032.

Referral Document

Appeals Council Decision

 
  
Copyright 2010 by Q2 Administrators. LLC. All Rights reserved