SS Denials - JA DME

Same or similar denials occur when the beneficiary's history indicates an item is the same or similar to the item being billed. Some examples of same and similar items are E0196 (gel pressure mattress) with E0277 (powered pressure-reducing air mattress), E0250 (hospital bed, fixed height, with any type of side rails, with mattress) with E0261 (hospital bed, semi-electric, with any type of side rails, without mattress) and same or similar orthotics.

Prior to providing an item, and to gain the necessary information required to determine whether an Advance Beneficiary Notice of Noncoverage (ABN) should be obtained or not, it is best to verify same or similar details within the Same or Similar functionality in the Noridian Medicare Portal (NMP) or via the Noridian Interactive Voice Response (IVR) System.

The beneficiary or caregiver is another important source in determining whether same or similar items have previously been provided. Suppliers should ask the beneficiary or caregiver if they have received similar items in the past.

• Has there been a change in the beneficiary's medical condition that supports the need for a same or similar type of item?
• Has the original item been lost, stolen, or irreparably damaged?
  • Answering these questions will help determine whether an Advance Beneficiary Notice of Noncoverage (ABN) should be obtained
• Has the beneficiary had a same or similar item?
  • If he/she has not had a same or similar item, bill claim without obtaining an ABN (no ABN necessary)
  • If he/she has had a same or similar item, determine if item has reached its RUL
    • If RUL reached, bill claim without ABN (no ABN necessary)
    • If item has not reached RUL, obtain an ABN and bill claim with applicable GA modifier

It is important to note that the IVR and NMP will confirm that a beneficiary either has or has not had a same or similar item with Jurisdiction A. It is the supplier's responsibility to check other jurisdictions for same or similar, including Jurisdiction D, if there is reason to believe that the beneficiary may have obtained a same or similar item within a different jurisdiction. The claims in the NMP are specific to each Jurisdiction so each Jurisdiction, JA and JD, may need to be verified along with other jurisdiction's portals for same or similar.

DME suppliers are expected to be familiar with DME coverage policies and any additional pertinent information that may have an impact on medical necessity determinations. In order to be protected under the limitation of liability provision, a supplier must provide a proper Advance Beneficiary Notice of Noncoverage (ABN) for each item that it believes is likely to be denied as not medically necessary.

If there is no indication that same or similar equipment has been previously obtained, the supplier would not have reason to provide an ABN. If the beneficiary or the beneficiary's authorized representative is unable to respond fully on the issue of "same or similar equipment," the supplier may issue an ABN. In situations where the beneficiary is planning to use an item as a backup (e.g., an extra wheelchair to keep in the car), the supplier should always obtain a signed ABN. A signed ABN is indicated on the claim form with a GA modifier.

If a claim is denied due to same or similar claims previously paid, suppliers should submit a redetermination. Supporting documentation would need to be included with the redetermination request. Noridian encourages Redeterminations/Appeals be submitted using the Noridian Medicare Portal.

Examples of applicable documentation to include:

• Standard Written Order
• Signed pick-up and delivery tickets, if applicable
• Copy of medical record to substantiate change in medical condition
• If item was lost stolen or irreparably damaged (specific incident) documentation from beneficiary statement, police report, fire report, or insurance claim information, etc. as applicable
• Copy of ABN if obtained