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Issue Number - Name
0079 - Ventilators Subject to DWO Requirements on or after January 1, 2016
Review Type
Complex
Claim Type
DME by supplier; DME by physician
Region and State
RAC 5
All States
Date Approved
2017-12-12

Description

Documentation will be reviewed to determine if Ventilators meet coverage criteria and/or are medically reasonable and necessary.

Affected Code(s)

  • E0465, E0466

Applicable Policy References

  • 42 Code of Federal Regulations, Sections 405.980 (b)&(c) and Section 405.986
  • 42 Code of Federal Regulations, Section 424.57(a)(12)
  • Title XVIII, Social Security Act, Section 1833(e)
  • Title XVIII, Social Security Act, Section 1862(a)(1)(A)
  • CMS Pub. 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 4, Section 4.26
  • CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2.4–5.2.8, 5.7, 5.8, and 5.9
  • CMS Pub. 100-04, Medicare Claims Processing Manual, Chapter 20
  • CMS Pub. 100-03, Medicare National Coverage Determination Manual, Chapter 1, Part 4, Section 280.1 and Section 240.5
  • CMS Policy Article, A55426, Effective date 01/01/2017