Description
More than one spring powered device per 6 months is not reasonable and necessary.
Affected Code(s)
A4258
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B
4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
5. 42 Code of Federal Regulations (CFR), §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. 42 CFR §405.929- Post-Payment Review
8. 42 CFR, §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions
9. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
10. 42 CFR, §414.210(f)- Payment for Replacement of Equipment
11. Medicare National Coverage Determination Manual, Chapter 1, Part 1, §40.2- Home Blood Glucose Monitors
12. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare
13. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies
14. Medicare Program Integrity Manual, Ch. 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
15. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33822- Glucose Monitors; Effective 10/01/2015; Revised 04/16/2023
16. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article A52464- Glucose Monitor- Policy Article; Effective 10/01/2015; Revised 04/16/2023
17. HCPCS Level II Codebook