Article Detail - JA DME

Suppliers should obtain documentation from the patient's medical record to ensure that coverage criteria have been met. It is expected that the beneficiary's medical records will reflect the need for the care provided and support that the coverage criteria have been met.

The medical records must:

• Support utilization
• Address
  • Symptoms
  • Continuing response/need for therapy
  • Diagnosis
  • Duration of condition
  • Clinical course (worsening or improvement)
  • Prognosis
  • Nature and extent of functional limitations
  • Other therapeutic interventions (and results)
  • Previous experiences with related items
• Support that item continues to remain reasonable and necessary
  • Continued medical need must be timely for DOS under review and is defined as a record within the preceding 12 months

Continued coverage for external insulin pumps and supplies require:

• An evaluation by the treating practitioner every 3 months

Administration of parenteral inotropic therapy requires:

• An evaluation every 3 months by prescribing provider or heart failure team with oversight by a cardiologist with training in management of advanced heart failure

Refer to the Noridian Medicare External Infusion Pumps webpage for additional resources.