ACM Q and A - November 19, 2025 - JD DME

The following questions and answers (Q&As) are cumulative from the DMEPOS Ask the Contractor Meeting (ACM). Some questions have been edited for clarity and answers may have been expanded to provide further details. Similar questions were combined to eliminate redundancies. If a question was specific to one supplier, Noridian addressed it directly with the supplier.

Questions Received Prior to ACM

Q: Why can a doctor of podiatric medicine (DPM) no longer write a prescription for pneumatic compression devices (PCDs)?
A: A DPM may write a prescription if they are allowed to order PCDs within their state.

Q: Why does each region have different rules for education audits?
A: Regional differences in Medicare education audits exist because contractors are given discretion to focus on specific areas of improper billing within their local jurisdictions and how to address them. Contractors analyze billing data to identify unusual practices in the specific region. Each contractor determines audit practices based on Local Coverage Determination (LCD) and Policy Article (PA) rules and regulations (when no national coverage determination exists).

Q: Are telehealth appointments for a face-to-face for power mobility still valid after September 30, 2025, and are they a permanent change?
A: CMS published Telehealth FAQ Calendar Year 2026 updated November 14, 2025, that states, "Through January 30, 2026, beneficiaries can receive Medicare telehealth services anywhere in the United States and territories. Starting January 31, 2026, except for behavioral health services, beneficiaries will generally need to be in a medical facility and in a rural area to receive Medicare telehealth services."

Q: Why is code OA-100 (other adjustment/payment made to patient) being used? We are a participating provider and it's typically only a partial portion of the total payment.
A: Please reach out to the Contact Center so they can look up your claims and provide up-to-date information.

Q: If a patient has been diagnosed with obstructive sleep apnea (OSA) but is not tolerating their positive airway pressure (PAP) device, the provider ordered an overnight pulse oximetry and the patient is dropping at or below 88%, can they get oxygen through Medicare? I have been saying no as my understanding is they must treat the OSA prior to adding oxygen. I have been asked by providers what other means they need to treat OSA. I have found that oral appliances, Inspire, and weight loss are the primary treatments, but I am concerned that their oxygen is falling below 88%. Does that put them in danger?
A: Medicare will not cover oxygen for a patient with OSA unless the OSA is appropriately treated first. Oxygen saturation results (e.g., dropping below 88%) during sleep are not considered valid for oxygen qualification if the OSA is untreated or if the patient is non-compliant with therapy. A titration sleep study is required to confirm effective treatment before oxygen can be considered. Please review the Oxygen and Oxygen Equipment Local Coverage Determination.

Noridian Medicare website > Policies > Local Coverage Determination (LCD) > Active LCDs Noridian Medicare website > Browse by DMEPOS Category > Oxygen

Q: Regarding bone stimulations, does adjacent segment disease (ASD) relate at all to a failed fusion?
A: ASD is not listed as a covered indication in National Coverage Determination (NCD) 150.2. Since ASD refers to degeneration at spinal levels adjacent to a prior fusion, it is not considered a failed fusion under CMS definitions. Coverage for bone stimulators requires documentation of nonunion or pseudarthrosis at the fusion site, not adjacent degeneration.

Q: What are Medicare's requirements for Positive Airway Pressure (PAP) therapy when a beneficiary transitions from Medicaid to Medicare and when is a new sleep study needed?
A: For beneficiaries new to Medicare who are already on PAP therapy, there must be documentation of the most recent sleep study meeting Medicare's current criteria, as well as a clinical evaluation on or after Medicare enrollment documenting a diagnosis of obstructive sleep apnea (OSA) and continued use. A new Standard Written Order is required to begin billing Medicare Fee-for-Service.

Noridian Medicare website > Browse by DMEPOS Category > Positive Airway Pressure (PAP) Devices

Q: When looking up same and similar online, some beneficiaries do not show that they received items recently from another supplier. Why does this happen?
A: Suppliers have 12 months to submit their claims. This could be one of the issues. Also, if a beneficiary received an item from a different supplier who billed a different jurisdiction, that item will not appear in the Noridian portal.

Q: If a Standard Written Order (SWO) has one provider's name on it but another or maybe even the wrong national provider identifier (NPI) on it, is a new SWO required?
A: A new SWO is required. The name must be consistent with the NPI.

Q: For oxygen qualification within 48 hours of hospital discharge, must the rest/exercise/nocturnal be signed and dated by the physician and include an NPI?
A: The supporting medical records must include the results of testing conducted no earlier than two days prior to discharge. The records must be signed by the treating practitioner or include their NPI and must be dated. Signature requirements are outlined in the IOM.

Internet Only Manual (IOM), Publication 100-08, Chapter 3, Section 3.3.2.4

Q: If a beneficiary is on a Group 3 Pressure Reducing Support Surface (PRSS) and the five-year reasonable useful lifetime (RUL) is met, if the beneficiary still qualifies, is conservative treatment needed again to get new equipment and bill?
A: To replace a Group 3 air-fluidized bed after its RUL is met, a new SWO is required to confirm ongoing medical necessity. The supplier will also need supporting documentation explaining why replacement is necessary. Conservative treatment is not needed again.

Q: Is atrial fibrillation (AFib) considered a covered secondary diagnosis for a continuous positive airway pressure device (CPAP) when the apnea-hypopnea index (AHI) is less than 15?

A: The National Coverage Determination (NCD) 240.4 indicates a CPAP is covered when the AHI is between 5-14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke. AFib is not a covered diagnosis. For CPAP to be covered under these conditions, the sleep study must also show an AHI of 5-14 events per hour, and the patient must have documentation of AFib (or other specified symptoms/conditions) along with their sleep apnea diagnosis.

Q: An amyotrophic lateral sclerosis (ALS) patient is getting a bilevel positive airway pressure (BIPAP) adaptive servo-ventilation (ASV) E0471, but they don't have a diagnosis of chronic obstructive pulmonary disease (COPD). Does that still need to be documented in the face-to-face exam as not contributing?
A: ALS may qualify under restrictive thoracic disorders. Under Criterion C, the fact that COPD does not contribute significantly to the beneficiary's pulmonary limitation would need to be documented.

Q: How can we get the accessories (i.e., liners, knitting marks) paid for on custom garments?
A: An accessory that is medically necessary for the effective use of a lymphedema garment (including custom) must use HCPCS code A6593. Each accessory must be on a separate claim line and must include a narrative (narrative requirements below included on the Lymphedema webpage). Right (RT) or left (LT) must be indicated if that applies. The medical record must indicate the necessity and reason for the specific accessories in the treatment of lymphedema.

To process the claim correctly, the claim must indicate what it is, what it is for, and the Supplier Price List (PL) amount.

Narrative requirements:

• Description of the item (including quantity represented by each unit of service (e.g., per inch, foot, or yard for supplies))
• Manufacturer name
• Product name, model name and number
• Supplier Price List (PL) amount (supplier's usual and customary charge)
• HCPCS of related item (where applicable)

Noridian Medicare website > Policies > Medical Director Articles > 2025 > Lymphedema Compression Treatment Items - Correct Coding and Billing - Revised

Noridian Medicare website > Browse by DMEPOS Category > Lymphedema Compression Treatment

Q: Is the Durable Medical Equipment (DME) oxygen order considered part of the beneficiary medical record?
A: The order is a general documentation requirement to justify payment for DMEPOS items. It is not considered part of the medical record.

Noridian Medicare website > Browse by Topic > Documentation > Medical Records

CMS Internet Only Manual Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.9 and 5.10

Q: I am looking for supporting references of DME coverage/non-coverage on a ventilator for an emergency only (EO) recipient. While DME is for in-the-home and not for acute needs, I am not finding other supporting references other than the plan definition of DME and EO.
A: Please reach out to Part B for supporting references regarding emergency equipment.

Q: Are the face-to-face requirements necessary for providing replacement supplies (liners, sleeves, socks, etc.) and repairs or is it just for a new order?
A: The Standard Documentation Requirements Policy Article A55426 indicates that for ongoing supplies there must be information in the beneficiary's medical record to support that the item continues to be reasonable and necessary. That could include a recent order/prescription by the treating practitioner for supply refills. Regarding repairs, the reason for the repair must be documented in the supplier's record and either the treating practitioner or the supplier must document that the repair itself is reasonable and necessary. A new SWO is not needed for repairs.

Verbal Questions Received During ACM

Q: Generally, an amputee would need liners for the prosthetic replaced every six months. By that time, because they have two, one to wear and one to wash, they wear out, depending on the activity level of the beneficiary. The beneficiary calls stating a new liner is needed. We've been told that we need to obtain a new order from the physician, the physician needs to document that we are requesting this, and there has to be continuity of care with the beneficiary and the provider. This is due to the liner being a component and the prosthesis is not functioning without it. Is this accurate?
A: A SWO must be obtained for each liner replacement. The supplier or the physical therapist needs to document the medical necessity (such as the liner being worn out, damaged, or no longer functional). However, the beneficiary is not required to have a face-to-face visit with the physician for this order. If physician's notes are submitted, they must document why the liner was required.

Follow-up Question: There is a list of requirements for face-to-face (F2F) exams, but just because an item is on that list, that doesn't mean the F2F is required, for example, replacement liners or supplies. Is this correct?
A: Supplies do not require a F2F, but components do to make sure they are reasonable and necessary. The first time the beneficiary receives the order, the F2F is required.

Follow-up Question: For example, when a beneficiary comes in and states their device is not functioning properly, they may have had an anatomy or status change, but they haven't seen their doctor in a good amount of time, we write a letter to the doctor letting them know what we've seen, we'd like to see your beneficiary, and if in agreement, please provide this within your medical record. Generally, it works out because they see what we see. Is this a safe practice?
A: The Education team can't approve medical record practices or approve medical records.

Q: One of the Skilled Nursing Facilities (SNFs) we work with has not received the CMS welcome letter so they cannot add start and end dates. Our setup for oxygen was after the beneficiary was discharged from the SNF, but we can't bill because the SNF can't enter the end date. When they call Medicare, they are told they need to wait for the letter. At this point, my claims are building up and all I can do is appeal, but I don't have documentation to support. Can I use an Advance Beneficiary Notice of Noncoverage (ABN), even though they've been at home since the setup was after the discharge?
A: This is a business practice decision. We are unable to change this in DME; you need to work with the SNF to get it updated. Once it's updated in the Common Working File (CWF), then the claims can be processed. There is a possibility the claims will deny for timely filing; however, continue billing so you can continue with the appeals process, if that's a possibility. When submitting appeals, state what happened, reviewers are looking at the documentation submitted. An ABN in this scenario will not change liability as the original denial (inpatient denial) is not a liability denial.

Q: I believe Medicare stated they reinstated the telehealth visit but was there any lapse in that?
A: From a DME standpoint, whatever is covered through Part B DME will accept for telehealth medical records. Please work with your Part B contractor on what telehealth is covered.

Q: When using the Noridian Medicare Portal (NMP) to check eligibility, we find that many Medicare beneficiaries have new ID numbers and when they call us, they are not providing that information to us. Why is it we can enter the old Medicare number in the portal and it states eligible, but a week later, I receive denial stating the beneficiary has a new ID number and it is not provided to us?
A: The Medicare numbers are cross referenced in the national file so if there is a new number, the old one cannot be used.

The first claim through the system is likely going to deny until that new Medicare number has been cross referenced. According to the Denial Code Resolution Tool, suppliers need to rebill with the correct Medicare ID, there are no appeals involved.

Noridian Medicare website > Browse by Topic > Remittance Advice (RA) > Denial Code Resolution

Follow-up Question: How do we, as a provider, know the number has changed?
A: Please work with the beneficiary to ensure all information is up to date and correct.

Q: If a beneficiary needs repairs on complex power mobility items that they own (purchased and under warranty but the manufacturer does not cover labor costs), are we able to bill for the labor for those repairs? We are receiving conflicting answers from an outside group and Noridian.
A: We cannot address another company's advice; but if the item is under warranty, it more than likely will not be covered under DME as replacement parts are not being paid by DME but under the warranty. You may offer an ABN and bill Medicare. With the ABN, the beneficiary is made aware that more than likely, Medicare will not pay for an item that is under warranty or for associated labor charges.

Written Questions Received During ACM

Q: Can we bill with an out-of-state provider? Also, how many bras can we bill at one time?
A: The supplier must be an enrolled Medicare DMEPOS supplier. The policy does not identify a specific quantity. Coverage for mastectomy bras is based on what is reasonable and necessary as determined by the prescribing physician and supported in the beneficiary's medical record.

Q: Is there any status on Medicare requiring accreditation surveys every year versus every three years?
A: We do not have any information on accreditation surveys. Please keep an eye out on the CMS website for any updates. Suppliers may also reach out to their corresponding National Provider Enrollment contractor with questions on accreditation.

Q: If a beneficiary has been diagnosed with lymphedema, do the chart notes need to talk about each specific garment each time they get new products?
A: Yes, Medicare expects the medical record to clearly document the medical necessity for each item being ordered, including:

• Type of garment (daytime vs. nighttime, sleeve vs. stocking, etc.)
• Compression level (e.g., 20-30 mmHg)
• Custom vs. off-the-shelf and why custom is needed (if applicable)
• Affected limb(s) and stage of lymphedema
• Quantity and frequency justification (e.g., 3 garments per body part every 6 months).

You can find additional information on our website.

Noridian Medicare website > Browse by DMEPOS Category > Lymphedema Compression Treatment.

Q: In the new Urological LCD, does "high level SCI (spinal cord injury)" include incomplete SCI? Does there have to be a level indicated in the medical record (MR)?
A: Yes. The LCD clarifies that immunosuppression occurs regardless of the vertebral level affected or the severity of SCI. This means both complete and incomplete spinal cord injuries qualify for the coverage criteria related to sterile catheter kits. The magnitude of immune suppression is greatest at higher levels, but the policy does not exclude incomplete injuries.

Q: If a beneficiary is getting a 90-day supply but we are only able to fulfill half of that 90-day supply, can we go ahead and bill the other half of the supplies as long as we submit it within the 90-day period? Example: 90-day supply of intermittent catheterization so 30 per month. Beneficiary gets 45 on December 1 and then comes back and gets the other 45 on December 25.
A: The date of service billed must be the date of delivery. So, billing on December 1 and December 25 could cause a denial for over utilization. Ensure a narrative is added for a 90-day supply and if a denial occurs, submit to appeals.

Q: How does Medicare pay as a secondary insurance? We have noticed our claims are denied when we bill Medicare as secondary.
A: Please work with the Contact Center on any issues regarding claim denials. You may also visit the Noridian Medicare Secondary Payer (MSP) webpage. Noridian Medicare website > Billing, Claims, and Appeals > Medicare Secondary Payer (MSP)

Q: With the new participating/non-participating rule, will payment be reduced for DME suppliers who are not participating but are accepting assignment?
A: We have not heard of a reduction in payment. Please work with the Pricing, Data Analysis and Coding (PDAC) contractor for any fee schedule payments.

Q: When can we expect a non-invasive positive pressure ventilation (NIPPV) LCD and PA for the new guidelines?
A: At this time, we do not have information on if or when this will be released by CMS.

Q: Are you taking any NIPPV questions related to the new NCD?
A: We are not taking NIPPV questions at this time. We will begin to educate when we have more information. Thank you for your patience. Please watch our schedule of events for upcoming education on NIPPV.

Q: Is there any movement towards accepting effective apnea hypopnea index (eAHI) for sleep apnea or oxygen studies? We're getting sleep studies scored with eAHI already and have to kick them back.
A: We have not heard of any updates to the sleep study. You can request an LCD reconsideration for this to be added to the LCDs.

Noridian Medicare website > Policies > Local Coverage Determination (LCD) > LCD Reconsideration Process

Q: Is there a plan to resume the Monday Live Chats or ramp up provider education again? CGS' website is loaded with classes for providers, but the Noridian offerings have severely declined in the last few months.
A: Noridian is committed to increasing our supplier self-service education at this time, utilizing the Noridian Educational Experience (NEE). Please watch our schedule of events and Webinar on Demand Recordings.

Noridian Medicare website > Education and Outreach > Noridian Educational Experience

Noridian Medicare website > Education and Outreach > Webinar on Demand Recordings

Q: For a Pressure Reducing Support Surface - Group 2, how often is the supplier responsible to document communication on an ongoing basis with the clinician providing the wound care in order to accurately determine that use of the KX modifier still reflects the clinical conditions which meet the criteria for coverage?
A: The LCD does not prescribe an interval for supplier communication with the clinician. The expectation is that the supplier must maintain ongoing documentation that the clinical conditions continue to meet coverage criteria.

Q: For a beneficiary transitioning to Medicare on Noninvasive Positive Pressure Ventilation with Chronic Respiratory Failure Consequent to COPD, is new testing required following enrollment in Medicare?
A: The most recent test will be accepted that meets Medicare coverage requirements.

Q: Does Medicare currently accept telehealth appointments for urological supplies considering the changes that were made during the government shutdown? If so, what qualifies as a telehealth appointment?
A: DME Medicare accepts covered Part B telehealth. Please note telehealth requirements changed on October 1, 2025. Please work with the Part B contractor for coverage of telehealth.

Telehealth HHS.gov

CMS Telehealth FAQ Calendar Year 2026

Follow-up Question: Can you please provide a link to find out more information about telehealth appointments?
A: CMS provides information and resources on telehealth services, additions, changes, review criteria, and more.

Q: What is the process when a supplier receives a denial for consolidated billing? How does the supplier bill the Home Health Agency (HHA)? Do we use the CMS-1500 form as well as create an invoice?

A: The DME MAC cannot advise on how to bill the HHA. Please refer to the agency in question for billing guidance.

Q: Does the new doctor need to review the old oxygen saturation (SATs) on an oxygen RUL?
A: This is not a requirement within the LCD for the RUL.

Q: Regarding oxygen due to an acute condition, if the beneficiary has to do a re-evaluation F2F and SATs, after that, do they continue to have the 61-90-day re-evaluations or are they then good for however long the doctor determines, (excluding the continued need requirement)?
A: Yes, after the 60-90-day re-evaluation for Group 2 or 3, the requirement is met.

Q: Is there anything in the works where Part B DME is voicing the challenges that suppliers are having with the SNFs not updating the discharge date, which prevents suppliers from being able to bill/get paid when the beneficiary is at home?
A: The SNF also has a year to bill Medicare. This unfortunately can be an issue for DME suppliers. It is important to work with the beneficiaries to ensure they are not in an inpatient stay on the date of service.

Q: What options do we have for obtaining a patient responsibility (PR) denial when the beneficiary is still in a Part A stay (within the 100 days). The secondary insurance is going to pay but we need the PR Medicare Explanation of Benefits (EOB)? The power mobility device (PMD) is needed at the facility for the beneficiary to be trained on that specific one that was made for that beneficiary, which can require more than two days of training.
A: A non-medical necessity denial will be received for an inpatient stay. There is no way to change the type of denial received during an inpatient stay from DME.

Q: Where can I find coverage criteria for L3908 (wrist/hand orthosis)? There isn't an LCD.
A: There is no LCD or PA for the orthosis mentioned. Please view the article below for more information.

Noridian Medicare website > Policies > Medical Director Articles > 2021 > Correct Coding of Finger, Hand, Hand-Finger and Wrist-Hand- Finger Braces (Orthoses) - Revised.

Q: For Targeted Probe and Educate (TPE) audits for smaller suppliers, the initial number of claims has changed from 10 to up to 20. Does that mean that the audit review is no longer annual, and one will be every year and a half or two years?
A: Continuation with TPE reviews will depend on the outcome of the original review. More information can be found on the Noridian website.

Noridian Medicare website > Medical Review, ADMC, and Prior Authorization > Targeted Probe and Educate (TPE)

Q: We have a denial where the NMP initially showed inpatient, it was later updated to show for a specific date, that there was no inpatient/Hospital/SNF stay. However, when we bill, it denies for inpatient. When we call the Contact Center we are told that there is something behind the scenes that we can't see, but the beneficiary is still showing as Inpatient/Hospital/SNF on that day. How are providers supposed to provide DME when the NMP shows us one thing and it isn't correct? What do you suggest?
A: The supplier needs to work with the beneficiary to ensure they are not inpatient when items are dispensed, as well as the facility to ensure the discharge record is updated. The DME MAC cannot update these records. If a denial is received, suppliers may appeal the denial after the facility has updated their records to the appropriate discharge location.

Q: When Medicare paid 13 months for a PAP device, do we have to have proof of training and a new capped rental letter for an RUL or is if ok not to have it if we have the signed documents from the original set up from five years ago?
A: This is not a requirement for the RUL. A new SWO and proof of delivery is required and indication of continued need.

Q: For surgical dressings, can the evaluation be conducted via telehealth or telephone encounter?
A: Please refer to your Part B Medicare contractor for guidelines on telehealth.

Q: For a beneficiary being prescribed oxygen who also has an OSA diagnosis, our understanding is a qualifying polysomnogram (PSG) is required to qualify for oxygen. If the beneficiary has a concurrent OSA, would there be any diagnosis where a PSG is not required when qualifying for oxygen (example: congestive heart failure (CHF) or restrictive lung disease)?
A: If there is a diagnosis of OSA the PSG is required. No other diagnosis is listed within the LCD that would require the PSG.

Q: Regarding the Group 3 PRSS five-year RUL rule and having to repeat conservative treatment, if a beneficiary has a Medicare Advantage (MA) plan when the PRSS Group 3 is delivered but then decides to switch to traditional Medicare, will conservative treatment be required again with the start of Medicare or can this change be documented?
A: When a beneficiary transitions to Medicare Fee-for-Service (FFS), Medicare does not automatically continue coverage for items obtained under another payer. The first claim to Medicare FFS is treated as a new initial rental. For more information, please visit our website.

Noridian Medicare website > Billing, Claims, and Appeals > Billing Situations > Beneficiaries Entering Medicare

Q: For a continuous glucose monitor (CGM), a six-month follow-up is required from the date of the order. Does it need to be on the sixth month or within the six months. Is there a specific timeframe? What happens if they are seen after the sixth month? Along with that, if a 90-day supply is dispensed in the sixth month but the beneficiary has not been seen for the follow-up, can we bill for the remaining amount of the supplies after the follow-up?
A: If a 90-day supply is shipped in the sixth month but the follow-up visit has not occurred:

• Medicare requires that coverage criteria be met at the time of dispensing.
• If the visit is overdue, you cannot bill for supplies shipped after the six-month window until the follow-up visit is completed.
• Once the visit occurs, coverage resumes, and you can bill for supplies going forward, but not retroactively for the gap period.

Follow-up Question: Does the follow-up have to be in the sixth month, or can they be seen prior to the sixth month?
A: It needs to be within the sixth month. If they are seen sooner than the sixth month you will still need one in the sixth month.

Follow-up Question: Can we bill for the remaining two months of supplies that were already shipped prior to the follow-up visit if they are seen after the 90-day supply has been shipped but prior to the second month for that three-month supply period?
A: Yes.

Follow-up Question: If the CGM follow-up visit is due in September, we ship supplies in September but before they are seen, we cannot bill for those supplies shipped for the month of September since they were not seen prior to dispensing?
A: The supplies should not be billed if they are not in compliance. If they become compliant in the next month the other two months can be billed.

Q: Do you have any updated information on competitive bid for 2026?
A: We do not have any additional information on competitive bid. Please review the Competitive Bid Contractor's website for any/all updates.

CMS.gov DMEPOS Competitive Bidding

DMEPOS Competitive Bidding Program

Q: If there is a mismatch on the SWO between the name and NPI, if the clinical notes submitted confirm the name of the provider is a match, do we need a new SWO? Example: Name on the SWO is for Adam Jones but the NPI is for Jenny Smith, and the notes confirm Adam Jones is the one who treated the patient. Is a new SWO required?
A: A new order is required if there is a change to the order. If there is a name/NPI mismatch a new order would be needed.

Q: When a therapy evaluation is completed for positioning components on a power chair, is it necessary that the word "significant" is required or just stated the patient has postural asymmetries?
A: The word significant is not a requirement within the medical record. The medical record should reflect the need for the positioning components for that specific patient.

Q: Will the K083/K0831 (power wheelchairs) be added to submit a prior authorization (PA) soon?
A: We have not heard from CMS if these wheelchairs will be added to PA. If an update is made, we will post to our website.

Q: On a SWO, if a doctor signs but it was the incorrect doctor, can the correct doctor sign and date below the others, or do we need to get a new one?
A: A new order is required if there is a change to the order.

Q: If an ABN is forgotten upon delivery, can you get one dated after the delivery date?
A: No, you cannot retroactively date an ABN. Medicare requires that the ABN be presented before delivery of the item or service so the beneficiary can make an informed decision. If the ABN is signed after delivery, it is considered invalid, and the supplier assumes financial liability for the item.

Q: When a beneficiary who is actively renting equipment through a commercial payer obtains Medicare as their secondary payer halfway through their rental, is a new proof of delivery (POD) attestation (showing equipment is in good working order) required to be signed by the beneficiary prior to billing the secondary Medicare rental claim?
A: When a beneficiary transitions to Medicare Fee-for-Service (FFS), Medicare does not automatically continue coverage for items obtained under another payer. The first claim to Medicare is treated as a new initial rental.

Follow-up Question: Can you tell us what would be required while actively renting a CPAP through a commercial payer and then obtaining Medicare secondary part way through an active rental when their medical records already met Medicare guidelines?
A: Coverage criteria will need to be met, including documentation requirements. For more information, please visit our website.

Noridian Medicare website > Billing, Claims, and Appeals > Billing Situations > Beneficiaries Entering Medicare.

Q: Can an E2310 (electronic connection between wheelchair controller and one power seating system motor) ever be billed with a K0831, which is a no power option chair?
A: E2310 can only be billed if the chair includes a power seating system motor (e.g., tilt or recline). If the chair truly has no power seating option, E2310 cannot be billed.

Q: For feeding kits to be covered, must the formula also be submitted and covered by Medicare?
A: Supplies and accessories are covered for medically necessary nutrition. Supplies and equipment are considered accessories to the enteral nutrition benefit, so if the formula is not covered, the related supply allowance (kits) will also be denied.

Q: Would AFib meet the requirements of a condition needed in addition to OSA when the AHI is less than 15? We do not see that it meets one of those conditions, so we are asking the physician if they have any of the conditions such as hypertension that is documented, and they are saying AFIB is considered the same for the condition requirement for when AHI is less than 15. We cannot find anywhere that says this is acceptable.
A: AFib does not meet the Medicare criteria for CPAP coverage when AHI is less than 15. Documentation of one of the listed conditions (e.g., hypertension, ischemic heart disease, or prior stroke) or symptoms like excessive daytime sleepiness, is needed.