Same or Similar Denials

Same or similar denials occur when the patient's CMN history indicates a piece of equipment is the same or similar to the equipment being billed. Some examples of same and similar items are E0196 (gel pressure mattress) with E0277 (powered pressure-reducing air mattress) and E0250 (hospital bed, fixed height, with any type side rails, with mattress) with E0261 (hospital bed, semi-electric, with any type side rails, without mattress). To determine whether same or similar items have previously been provided, suppliers must obtain all possible information from a patient, which may include the following:

  • Patient's correct Health Insurance Claim number;
  • Whether the patient has employer insurance or is enrolled in a Health Maintenance Organization (HMO);
  • If the patient currently has or had an identical or similar item in the past;
  • When the patient received the items and whether or not the items have been returned;
  • Where the item will be used; and
  • CMN or DIF information, if required.

By using the Suggested Intake Form, it assures this information is obtained. This form is available on our website under the Forms section and it contains beneficiary information, ordering physician information and questions for the beneficiary and the supplier. Suppliers can customize their own intake form to meet their needs as well.

The supplier should also make sure the patient understands that items such as wheelchairs and power-operated vehicles are considered similar equipment and that Medicare usually will not cover both items at the same time. If submitting a claim for a POV and the patient already has a wheelchair, for example, include narrative information regarding the medical necessity for the previous equipment, when and why that need ended, the new or changed medical condition for the POV, when that need began and any additional required information.

To verify the patient has not had a same or similar item previously, suppliers can utilize the Noridian Medicare Portal (NMP) or the IVR.

The supplier enters their NPI, PTAN, last five digits of the Tax Identification Number, the beneficiary's Medicare ID, the beneficiary's first and last name, the beneficiary's date of birth, and the HCPCS code. The IVR and portal research and return the claim history and supplier information for applicable claims processed within this jurisdiction as well as by other DME MACs by researching the Common Working File for that HCPCS code. 

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 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. 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 can submit a redetermination. Supporting documentation would need to be included with the redetermination request. Examples of applicable documentation include the CMN or DIF, physician order, signed pick up and delivery tickets, a detailed outline of events and any changes in medical need and a copy of the ABN.

 

Last Updated Fri, 23 Feb 2018 12:38:59 +0000