DME MAC JURISDICTION C - CGS

Supplier Documentation Chapter 3The supplier should make certain that the beneficiary understands that items such as wheelchairsand power-operated vehicles are considered "similar equipment," and that Medicare will not coverboth items when they are used simultaneously. The supplier should strongly encourage thebeneficiary to inform the supplier if the medical need for the item changes and the beneficiaryrequires a different piece of equipment that serves a similar purpose. The Medicare program willonly allow items that meet the beneficiary’s current needs.For example, if a beneficiary is renting a manual wheelchair and his/her condition worsens to thepoint that only a different wheelchair, such as a power wheelchair, will meet his/her medical need,coverage will be allowed for the power wheelchair and the manual wheelchair will be denied assame or similar equipment.If there is no indication that same or similar equipment has been previously obtained, the supplierwould not have reason to provide an ABN. If the beneficiary or the beneficiary’s authorizedrepresentative is unable to respond fully on the issue of "same or similar equipment," the suppliermay issue an ABN. In situations where the beneficiary is planning to use a piece of equipment as abackup (e.g., an extra wheelchair to keep in the car), the supplier should ALWAYS obtain a signedABN. Please submit a copy of the ABN with each appeal request.Same or similar rules may not necessarily apply to situations where a new device with additionaltechnological features becomes available. The DME PSC must evaluate whether the new feature(s)meet the patient's medical need that is not met by the patient's current equipment. If the new featureor device meets a current medical need that is not met by the current equipment because theappropriate technology was not available at the time the patient obtained the item, even if there hasbeen no change in the beneficiary's condition, the 5-year useful lifetime rules do not apply and thenew item may be provided. However, if the new item is meeting the same medical need as the olditem but in a more efficient manner or is more convenient, AND there is no change in thebeneficiary's condition, Medicare will not reimburse for the new item.The following examples illustrate these instructions.1. The beneficiary receives a power wheelchair without power tilt/recline. Subsequently, it isdetermined that the beneficiary needs a tilt/recline AND he/she has needed it since theprovision of the initial power wheelchair. Often, the old wheelchair base will notaccommodate the new tilt/recline system; therefore, in addition to the tilt/recline, the supplierasks for a wheelchair base to be reimbursed. In this case one of the following options wouldapply:A. If the old wheelchair is rented, allow additional amount for the tilt/recline but not a new rentalperiod for the new wheelchair base.B. If the old wheelchair was purchased, allow only for reimbursement of the tilt/recline and notthe purchase of a new wheelchair base.2. Code E2101 represents a new code for a home glucose monitor that integrates the lancingand application of blood to the glucose testing strip in one machine. The Glucose MonitorsLocal Coverage Determination (LCD) allows payment for these devices for the beneficiarieswith manual dexterity problems. If a beneficiary had manual dexterity problems at the timeDME MAC Jurisdiction C Supplier Manual Page 14