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Issue Number - Name
0082 - Ventilators Subject to ACA Requirements
Review Type
Complex
Claim Type
DME by supplier; DME by physician
Region and State
RAC 5
All States
Date Approved
2018-02-13

Description

Identify claims for Ventilators that do not meet the indications of coverage and/or medical necessity.

Affected Code(s)

  • E0450, E0460, E0461, E0463, E0464

Applicable Policy References

  • 42 Code of Federal Regulations, Sections 405.980 (b)&(c) and Section 405.986
  • 42 Code of Federal Regulations, Section 410.38(g)(3) and (g)(4)
  • 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, Section 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