SS and ABNs - JA DME
Same/Similar Equipment and Advance Beneficiary Notices
Numerous claims for DME are denied because the equipment involved is the same as or similar to equipment already in the possession of the beneficiary. The statutory basis for denial of such claims is medical necessity; therefore, the limitation on liability provision under Section 1879 of the law applies.
- ANSI Reason Code M3 - "Equipment is the same or similar to equipment already being used."
Liability is assessed on claims denied based on "same or similar equipment." DME suppliers are expected to be familiar with DME MAC coverage policies and any additional pertinent information that may have an impact on medical necessity determinations. To be protected under the limitation on liability provision, a supplier must provide a proper Advance Beneficiary Notice of Noncoverage (ABN) for each item they believe will deny as not medically necessary.
There must be a specific, identifiable reason to believe that Medicare may not pay for certain DME items (e.g., "same or similar equipment"). Suppliers must obtain all the necessary information from a beneficiary to determine whether "same or similar equipment" has previously been provided to him/her.
When providing items to Medicare beneficiaries, suppliers should ask very specific questions and determine information such as:
- The beneficiary's correct Medicare ID;
- If the beneficiary has employer insurance or is enrolled in a Health Maintenance Organization (HMO);
- If the beneficiary currently has or had an identical or similar item in the past;
- When the beneficiary received the items and if the items have been returned;
- Where the item will be used; and
- Certificate of Medical Necessity (CMN) or DME Information Form (DIF) information.
A supplier should make certain a beneficiary understands that items such as wheelchairs and power-operated vehicles are considered "similar equipment," and that Medicare will not cover both items when they are used simultaneously. A supplier should strongly encourage the beneficiary to inform the supplier if the medical need for the item changes and if he/she requires a different piece of equipment that serves a similar purpose. The Medicare program will only allow items that meet the beneficiary's current needs.
For example, if a beneficiary is renting (HCPCS K0001) wheelchair and his/her condition worsens to the point that only a different wheelchair such as HCPCS K0823 will meet his/her medical need, coverage will be allowed for the HCPCS K0823 and the HCPCS K0001 will be denied as same or similar equipment. If there is no indication that same or similar equipment has been previously obtained, the supplier will have no reason to provide an ABN. If a beneficiary or his/her 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 a piece of equipment as a backup (e.g., an extra wheelchair to keep in the car), the supplier should always obtain a signed ABN. Please submit a copy of the ABN with each appeal request.
Same or similar rules may not apply to situations where a new device with additional technological features becomes available. The DME MAC must evaluate whether the new feature(s) meets the beneficiary's medical need that is not met by his/her current equipment. If a new feature or device meets a current medical need that cannot be met by his/her current equipment because the appropriate technology was not available at the time the beneficiary obtained the item, even if there has been no change in the beneficiary's condition, the five-year useful lifetime rules do not apply and the new item may be provided. However, if the new item is meeting the same medical need as the old item but in a more efficient manner or is more convenient, AND there is no change in the beneficiary's condition, Medicare will not reimburse for the new item.
The following examples illustrate these instructions:
A beneficiary receives a power wheelchair without a power tilt/recline. Subsequently, it is determined that he/she beneficiary needs a tilt/recline AND has needed it since the provision of the initial power wheelchair. Often, the old wheelchair base will not accommodate the new tilt/recline system; therefore, in addition to the tilt/recline, the supplier asks for a new wheelchair base to be reimbursed. In this case, one of the following options would apply:
- If the old wheelchair is rented, allow additional amount for the tilt/recline but not a new rental period for the new wheelchair base.
- If the old wheelchair was purchased, allow only for reimbursement of the tilt/recline and not the purchase of a new wheelchair base.
- HCPCS E2101 represents a home glucose monitor that integrates the lancing and application of blood to the glucose testing strip in one machine. The Glucose Monitors Local Coverage Determination (LCD) allows payment for these devices for beneficiaries with manual dexterity problems when the basic coverage criteria have been met. At the time that the HCPCS E0607 monitor was purchased, a beneficiary had manual dexterity problems but the technology of monitors HCPCS E2101 was not available when he/she obtained the HCPCS E0607. He/she will be allowed to purchase the HCPCS E2101 to address his/her medical need for a monitor that accommodates their dexterity problem. No "same or similar" denial applies. The HCPCS E0607 did not accommodate their medical need and while their medical need did not change, technology changed such that their medical need could now be met by the new technology.
These rules apply both when the new device with advanced features is classified by the same HCPCS as the older device and when described by a different HCPCS. If the new device is described by a different code, the beneficiary must also meet the coverage criteria of the new item.
- CMS Internet Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 110.1
- CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 30
Last Updated Thu, 19 Dec 2019 10:33:24 +0000