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MEDICARE DME Redetermination Request Form

REQUIRES MANUAL REDETERMINATION BY QUALIFIED MEDICAL PANEL

Supplier information

Supplier Name:
PTAN:
NPI:
Tax ID:
Address:
City:
State:
Zip Code:
Phone Number:
Requestor's Name/Supplier Contact Name:

Beneficiary information

Patient Name [REQUIRED]:
Medicare Number: [REQUIRED]
State:
Phone Number:
Requestor's Signature [REQUIRED]:
Date: [REQUIRED]
Diagnosis:

Specific Service or Item in Dispute [MANDATORY]

Date of Service:
Description of Items:
HCPCS & Modifiers:
Claim Number:
Date of Initial Determination:

Suggested Documentation Check List:

Medicare Remittance Advice (RA) or Medicare Summary Notice (MSN)
Certification of Medical Necessity/DIF/Physician's Written Order
Advance Beneficiary Notice of Noncoverage (ABN)
Medical Documentation

RATIONALE FOR DISAGREEMENT WITH INITIAL DENIAL

I disagree with the determination that the items in dispute are "not covered by Medicare" or that "Medicare does not pay for this item or service".

They are covered by statute and by Medicare documentation as "prosthetic devices" benefits. Relevant arguments and citations are as follows:

  1. For an item or service to be covered by Medicare:
    1. it must fall into a defined benefit category, defined in §1861(s) of the SSA,
    2. it must not be statutorily excluded, and
    3. it must be reasonable and necessary under §1862(a)(1)(A) of the SSA.
  2. Medicare Part B pays for the following medical supplies, appliances and devices (benefits):
    1. surgical dressings and splints casts and other devices used for reduction of fractures and dislocations [SSA §1861(s)(5) and 42 C.F.R. § 410.36(a)(1)];
    2. prosthetic devices, other than dental, that replace all or part of an internal body organ, including replacement of prosthetic devices [SSA §1861(s)(8) and 42 C.F.R. § 410.36(a)(2)];
    3. leg, arm, back, and neck braces and artificial legs, arms, and eyes, including replacements if required because of a change in the individual's physical condition [SSA §1861(s)(9) and 42 C.F.R. § 410.36(a)(3)];
    4. durable medical equipment if the equipment is used in the patient's home or in an institution that is used as a home [SSA §1861(s)(6), SSA §1861(n) and 42 C.F.R. § 410.38(a)].
  3. Benefits and coverage criteria are further defined by CMS in the Medicare Benefit Policy Manual, Chapter 15 — Covered Medical and Other Health Services [Revision 179, 01-14-14]
    1. § 100 — Surgical Dressings. Surgical dressings are limited to primary and secondary dressings required for the treatment of a wound caused by, or treated by, a surgical procedure that has been performed by a physician or other health care professional to the extent permissible under State law.
    2. § 120 — Prosthetic Devices. Prosthetic devices (other than dental) which replace all or part of an internal body organ (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ are covered when furnished on a physician's order.
    3. § 130 — Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes.
      These appliances are covered under Part B when furnished incident to physicians' services or on a physician's order. A brace includes rigid and semi-rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.
    4. § 110 — Durable Medical Equipment. Durable medical equipment is equipment which:
      • _Can withstand repeated use;
      • _Is primarily and customarily used to serve a medical purpose;
      • _Generally is not useful to a person in the absence of an illness or injury; and
      • _Is appropriate for use in the home.
    All requirements of the definition must be met before an item can be considered to be durable medical equipment.
  4. Where coverage of an item or service is provided for specified indications or circumstances but is not explicitly excluded for others, or where the item or service is not mentioned at all in the CMS Manual System the Medicare contractor is to make the coverage decision, in consultation with its medical staff, and with CMS when appropriate, based on the law, regulations, rulings and general program instructions. [Medicare National Coverage Determinations Manual, Chapter 1, Part 1, Foreword, §A]
  5. The Medicare Administrative Contractor for DMEPOS (DME MAC) is hereby requested to make a coverage determination for the compression items at issue, prescribed by the Beneficiary's physician for use as a part of the compression therapy of the Beneficiary's diagnosed lymphedema. The coverage criteria are found in the Medicare Benefit Policy Manual, CMS Pub. 100-02, Chapter 15, § 120. No NCD or LCD covers their use in the treatment of lymphedema, so the NCD Manual requires that the DME MAC medical staff make a determination based on this statute, and not based on the coverage criteria for other statutory benefit categories such as surgical dressings, durable medical equipment, splints and braces.
  6. The beneficiary is prepared to provide extensive medical evidence that these compression materials replace part of the function of the malfunctioning lymphatic system by:
    • Preventing reflux by reducing capillary filtration;
    • Increasing coupling between collectors and lymphatic & venous returns;
    • Increasing lymphatic uptake by increasing tissue pressure;
    • Stimulating pumping action of lymphangions (lymph vessels);
    • Increasing lymphatic flow rate by reducing lymphangion diameter;
    • Amplifying decongestive lymph-pumping effect of arm and leg muscles;
    • Breaking down fibrosed tissue
    • Providing support for heavy, aching limbs
    • Serving as a physical barrier protecting skin from further trauma
  7. 42 C.F.R. §405.956 Notice of a redetermination states in part:
    (b) Content of the notice for affirmations, in whole or in part. For decisions that are affirmations, in whole or in part, of the initial determination, the redetermination must be written in a manner calculated to be understood by a beneficiary, and contain—
    1. A clear statement indicating the extent to which the redetermination is favorable or unfavorable;
    2. A summary of the facts, including, as appropriate, a summary of the clinical or scientific evidence used in making the redetermination;
    3. An explanation of how pertinent laws, regulations, coverage rules, and CMS policies apply to the facts of the case;
    4. A summary of the rationale for the redetermination in clear, understandable language;
    5. Notification to the parties of their right to a reconsideration and a description of the procedures that a party must follow in order to request a reconsideration, including the time frame within which a reconsideration must be requested;
    6. A statement of any specific missing documentation that must be submitted with a request for a reconsideration, if applicable;
    7. A statement that all evidence the appellant wishes to introduce during the claim appeals process should be submitted with the request for a reconsideration;
    8. Notification that evidence not submitted to the QIC as indicated in paragraph (b)(6) of this section, is not considered at an ALJ hearing or further appeal, unless the appellant demonstrates good cause as to why that evidence was not provided previously; and
    9. The procedures for obtaining additional information concerning the redetermination, such as specific provisions of the policy, manual, or regulation used in making the redetermination.
    10. Any other requirements specified by CMS.
    (c) Content of the notice for a full reversal.
    For decisions that are full reversals of the initial determination, the redetermination must be in writing and contain—
    1. A clear statement indicating that the redetermination is wholly favorable;
    2. Any other requirements specified by CMS.

WHERE TO SEND REQUEST

This is not an official Medicare form. The form is designed so that the lymphedema patient can easily include all of the basic information needed to submit a redetermination request for denied lymphedema compression items and should be valid in all four DME MAC Jurisdictions.

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