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: If we have bilateral prosthetic orders that require two separate authorization numbers on a single order, are we able to submit them on one claim?
A: Bilateral prosthetic items must be billed on separate claims, with the respective authorization number and the RT/LT modifier for laterality.

• Noridian Medicare website > Browse by DMEPOS Category > Prosthetics

Q: For parenteral nutrition claims, if a beneficiary receives a single day supply of therapy, should the claim be billed with a date span? E.g., 01/01/2026-01/02/2026
A: Yes. For parenteral nutrition, date spans are required, even when only one day of therapy is provided.

• Noridian Medicare website > Billing, Claims, and Appeals > Claim Submission > Date Span Requirements on Claims

Q: In the Respiratory Assist Device (RAD) Local Coverage Determination (LCD) for central sleep apnea (CSA) and complex sleep apnea (CompSA), are mixed apneas categorized with central apneas, obstructive apneas, or are they considered separately?
A: Mixed apneas are not counted as central apneas for Medicare DME qualification under the RAD LCD for CSA/CompSA; only true central apneas and central hypopneas contribute to the central apnea index (CAI) requirement. Coverage requires a CAI ≥ 5 based on central apneas and central hypopneas, with no inclusion of mixed events. Because mixed apneas contain both obstructive and central components, they are considered separately and do not satisfy the central‑event criteria for RAD coverage.

• Noridian Medicare website > Browse by DMEPOS Topics > Respiratory Assist Devices

Q: Are we now required to append the SC modifier along with RT and LT modifiers for DME compression items?
A: Yes. As of January 2026, the SC modifier must be appended to the lymphedema compression items when all statutory and reasonable and necessary requirements have been met. Also include the RT and LT modifiers where laterality is indicated.

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

Q: If a beneficiary has a diagnosis of CSA and not obstructive sleep apnea (OSA), would a pulse oximetry test qualify them for oxygen therapy, or would a titration study be required?
A: If a beneficiary has CSA and not OSA, a sleep oximetry (pulse oximetry) test showing oxygen saturation ≤ 88% for at least five minutes during sleep (minimum two-hour recording) qualifies for home oxygen therapy, no titration study is required.

• Noridian Medicare website > Policies > Clinicians Corner > Clinicians Are You Ordering Oxygen for Your Patient

Q: The beneficiary owns a Continuous Positive Airway Pressure (CPAP) machine, and ResMed cannot obtain the part needed for repair. How should we bill for a replacement device if it is not within the five-year Reasonable Useful Lifetime (RUL) period?
A: If the CPAP machine is beyond its five-year RUL, bill for a replacement adding the RA modifier to the first claim submission for the PAP device. Have available upon request a new SWO and documentation of continued medical necessity.

• Noridian Medicare website > Policies > Clinicians Corner > Clinician Resource Letters > Positive Airway Pressure (PAP) Devices: Replacement

Q: If a capped rental item is returned during a month we have already been paid for, is a refund required?
A: Capped rental items do not require a refund if the item is returned during a month for which you have already received payment.

• Noridian Medicare website > Browse by Topic > DMEPOS Payment Categories > Capped Rental Items

Q: Which rental items will be included in competitive bid?
A: The Competitive Bidding Program (CBP) is still within the temporary gap period. Any changes or updates will be available on the CMS website.

• Noridian Medicare website > Browse by Topic > Competitive Bidding

Q: The current Active LCD and Policy Article for PAP devices states in several places that beneficiaries must have an in‑person evaluation with the treating practitioner. However, the Clinician Checklist for Positive Airway Pressure devices states that the beneficiary must have an in‑person or Medicare‑approved telehealth evaluation with the treating practitioner. This raises the question of whether a telehealth waiver is currently in place that would supersede the LCD or Policy Article?
A: CMS has instructed that through December 31, 2027, beneficiaries can receive Medicare telehealth services anywhere in the United States and territories. Starting January 1, 2028, except for behavioral health services, beneficiaries will need to be in a medical facility in a rural area to receive Medicare telehealth services.

• Noridian Medicare website > Browse by Topic > Documentation > Telehealth

Q: Are Medicare Railroad Board (RRB) claims submitted to the DME MAC?
A: Yes. For DME items, suppliers submit claims to the DME MAC, even when the beneficiary has RRB benefits.

Q: Is it permissible and/or compliant to bill Medicare for denial, if only for coordination of benefits (COB) purposes?
A: Suppliers may submit claims to Medicare for denial. Suppliers are required to submit claims in the appropriate payer order and follow Medicare billing requirements.

• Noridian Medicare website > Billing, Claims, and Appeals > Medicare Secondary Payer (MSP)

Q: Can Medicare Part B be billed for infusion services provided in an Ambulatory Infusion Suite (AIS) when the service location is outside the beneficiary’s home?
A: The Part B Home Infusion Therapy (HIT) benefit covers infusion therapy only when a skilled professional is in the beneficiary’s home and only when administering eligible home infusion drugs. Please refer to your Part B contractor for guidance.

Q: What information is required for retroactive entitlement?
A: Suppliers will be required to provide proof of medical necessity and meet documentation requirements based on policy for the DME items dispensed to the beneficiary. In addition, the supplier will be required to provide Medicare Secondary Payer (MSP) information, and proof of retroactive entitlement. Denied claims must follow the appeals process and include all applicable documentation. Refer to the Internet Only Manual for retroactive entitlement information.

• Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 1, Section 70

Q: If a beneficiary has not met compliance criteria for an E0601 (CPAP) but the beneficiary states they are non-compliant due to not having the correct supplies, can the beneficiary receive the correct supplies to become compliant, or will it still be denied?
A: For supplies to be covered, the beneficiary must meet compliance for the device. It is the supplier’s responsibility to ensure that the supplies dispensed for a DME device be appropriate for the fit and use of said device, in addition, documentation must show the mask/interface was properly fit and the beneficiary was able to use it without difficulty. Medicare cannot cover supplies to help the beneficiary become compliant. Supplies are only covered after coverage criteria have been met for CPAP.

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

Q: We noticed that the current Advance Beneficiary Notice of Noncoverage (ABN) has an expiration date of January 31, 2026. I have not seen any notification indicating that new forms have been issued. Could you please provide an update on how these should be handled?
A: The current guidance from CMS is that providers should continue using the existing ABN form, even though it shows an expiration date of January 31, 2026, because CMS has not yet released a new version. CMS has confirmed that the updated form is still undergoing the federal Paperwork Reduction Act review process, and the current form remains valid until a replacement is officially issued.

Q: I am a physician with a telehealth practice focused on helping beneficiaries obtain mobility equipment. I recently learned that when a beneficiary is replacing their wheelchair with the same type, a full wheelchair evaluation may not be required, only documentation from the physician confirming continued need and a Written Order Prior to Delivery (WOPD). I have been trying to apply this guidance for my beneficiaries, but many vendors are reporting that secondary insurers still require a full seating evaluation, which undermines the intended efficiency. Could you clarify whether secondary insurance plans are allowed to impose their own requirements, or whether they must follow the determination made by the primary payer?
A: While we cannot advise on secondary insurers coverage criteria or requirements, secondary payers are not obligated to follow Medicare’s documentation requirements. Secondary payers can require different or additional documentation outside of Medicare coverage rules.

• Noridian Medicare website > Browse by Topic > Repairs, Maintenance, and Replacement > Replacement

Q: If a pre‑filled syringe (PFS) drug cannot be used with the E0779 infusion pump because it does not fit, can the supplier still bill K0552 (supplies for external non-insulin drug infusion pump, syringe type cartridge, sterile, each)" for providing a syringe that does fit the pump?
A: Supplies must be medically necessary and actually used with the infusion pump. Claims for K0552 are not separately payable if an infusion drug is pre-packaged and supplied in a syringe type cartridge.

• Noridian Medicare website > Policies > Local Coverage Determination (LCD) > Active LCDs > Policy Article A52507

Q: When is the new SC modifier required for ventilators and their related supplies?
A: The SC modifier is appended to the claim line when all specified requirements in the National Coverage Determination (NCD) 240.9 have been met for the Home Mechanical Ventilation (HMV) and related supplies.

• Noridian Medicare website > Policies > Medical Director Articles > Medical Director Articles – 2025 > Correct Billing and Coding of Ventilators – Revised

Q: Should K0552 (supplies for external non-insulin drug infusion pump, syringe type cartridge, sterile, each) be billed per syringe or per dose?
A: K0552 is billed as "each" according to the policy and code definition.

• Noridian Medicare website > Policies > Local Coverage Determination (LCD) > Active LCDs > LCD L33794

Q: Does a beneficiary need a new entering Medicare provider face-to-face (F2F) visit every time they switch from Medicare Fee-for-Service (FFS) to Medicare Advantage then back to FFS?
A: No. To be considered for coverage, F2F visits must be timely for the item or service, support medical necessity, and align with FFS coverage requirements.

• Noridian Medicare website > Browse by Topic > Documentation

Q: Can a beneficiary-owned insulin infusion pump be replaced with a provider attestation if the original documentation is not available (e.g., labs etc.)?
A: Provider attestation alone is not sufficient for replacement. For items that Medicare purchased, items can be replaced after the RUL with an order reaffirming medical necessity. If Medicare did not pay for the items, the beneficiary must meet the medical necessity criteria.

• Noridian Medicare website > Browse by Topic > Repairs, Maintenance, and Replacement

Q: If an error is found on a WOPD required item after delivery of the item, what are the supplier's options?
A: For items that require a WOPD, a valid order must be obtained prior to the delivery of the item. In these cases, it may be necessary to pick up the item and redeliver.

• Noridian Medicare website > Browse by Topic > Documentation

Q: For a custom fabricated ankle foot orthosis (AFO) is the criterion expected to be permanent, and diagnosis driven, or does it have to be documented?
A: The beneficiary must meet basic coverage requirements for the AFO, but it is pertinent that documentation support the level of care provided. There must be detailed documentation in the treating physician’s records to support the medical necessity of a custom fabricated rather than a prefabricated orthosis. This information must be corroborated by the functional evaluation in the orthotist/prosthetist’s records.

• Noridian Medicare website > Policies > Local Coverage Determination (LCD) > Active LCDs > LCD L33686

Q: After reviewing the documentation requirements for power wheelchairs and power‑operated vehicles, I wanted to confirm the expectations for signature dates when an evaluation with a physical therapist or occupational therapist is involved. The guidance states that the beneficiary may be referred to a physical therapist or occupational therapist, but the physician must examine the beneficiary both before and after the evaluation, document their agreement with the findings, and sign and date the report. It also notes that the date the physician first sees the beneficiary is considered the date of the face‑to‑face encounter. However, we received a denial stating that the order was dated before the physician signed the physical therapy evaluation. Should the order date occur after the physician’s face‑to‑face visit with the beneficiary, or after the date the physician signs off on the physical therapy evaluation?
A: If the physical therapy or occupational therapy evaluation contains most of the information needed to meet Medicare’s coverage criteria, the treating practitioner must review and sign the therapist’s evaluation before completing the SWO.

• Noridian Medicare website > Policies > Clinicians Corner > Clinician Resource Letters > Documentation Requirements for Power Wheelchairs and Power Operated Vehicles

Q: A beneficiary undergoes a traditional polysomnography (PSG) to evaluate for OSA. The beneficiary is found not to have OSA, but the study shows oxygen saturation levels dropping below 88 percent. Since the beneficiary does not have OSA, can that PSG be used to qualify the beneficiary for home oxygen therapy instead of performing a separate overnight oximetry test?
A: The PSG shows a qualifying result and no OSA. This would be acceptable to qualify for oxygen.

Q: If a beneficiary has OSA but the provider is prescribing oxygen for a different diagnosis, such as chronic obstructive pulmonary disease (COPD), is titration sleep study still required?
A: The determination depends on the medical record documentation, and the treating practitioner’s stated reason for prescribing oxygen. If OSA is referenced and Medicare cannot clearly establish medical necessity, the claim may be denied if OSA coverage criteria are not met.

• Noridian Medicare website > Browse by DMEPOS Category > Oxygen

Q: During the exercise testing for oxygen, does the third step (ambulation with oxygen) need to include the liters per minute (LPM) that were used?
A: The Oxygen LCD L33797 does not specify the LPM must be listed. It would be good practice to include the information within the medical record.

• Noridian Medicare website > Browse by DMEPOS Category > Oxygen

Q: For Group 2 (pulmonary hypertension or cor pulmonale) it states, “determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG”. What documentation should we be looking for in this testing or do we need to be looking for testing? Do we just rely on the provider documenting hypertension? As a supplier what documentation do we need to maintain in our records for a Group 2?
A: To meet the criteria for Group 2, criterion B – 2, the medical records must provide the measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale on EKG. Actual tests do not need to be provided however the outcome of said test must be documented by a clinician within the medical record.

• Noridian Medicare website > Browse by DMEPOS Category > Oxygen

Q: For portable oxygen, does the provider need to state the exact phrase “the beneficiary is mobile in the home,” or would documentation such as “the beneficiary is ambulating” or “the beneficiary fell while walking to the barn” be sufficient to show that the beneficiary is mobile?
A: The exact phrase “the beneficiary is mobile in the home” does not need to be listed within the medical record. There must be a clear indication within the medical record that the beneficiary is ambulatory within the home.

• Noridian Medicare website > Browse by DMEPOS Category > Oxygen

Q: Is a new sleep study required when a beneficiary’s RUL is within the past five years, if Medicare paid for the original device under the 13‑month capped rental?
A: No. Medicare does not require a new sleep study to replace a PAP device after the five‑year RUL, even if the original device was obtained through the 13‑month capped rental or was grandfathered. Medicare does require a new in‑person clinical evaluation documenting continued need and use of PAP therapy.

• Noridian Medicare website > Policies > Clinicians Corner > Clinician Resource Letters > Positive Airway Pressure (PAP) Devices: Replacement

Q: Are we allowed to sell products to customers in other states? We have customers who call in for replacement items, and we ship to them.
A: You may ship DME items to customers in other states, but Medicare requires that you hold any DME license required by the state where the item is delivered. This applies to replacement supplies as well. For additional questions please contact the National Provider Enrollment (NPE) contractor for your state.

Q: How do we successfully bill Medicare as secondary to a commercial primary for payment reimbursement?
A: To successfully bill Medicare as secondary when a commercial insurance plan is primary, you must:

• Bill the primary insurer first: Submit the claim to the commercial plan and wait for their Explanation of Benefits (EOB).
• Submit the claim to Medicare with the primary EOB using the appropriate Medicare DME HCPCS: Medicare requires the primary payer’s adjudication information (denial, payment, or partial payment).
• Use the correct Medicare EOB information. Medicare will process the claim as secondary based on the primary payer’s payment and the beneficiary’s Medicare coverage.
• Ensure the beneficiary’s insurance information is updated with Medicare. If Medicare does not have the correct primary payer on file, the claim will reject. You may need to contact the Benefits Coordination & Recovery Center (BCRC) to update records.
• Noridian Medicare website > Billing, Claims, and Appeals > Medicare Secondary Payer (MSP) > MSP Contractor

Q: For night-time garments it shows that payment is once every two years. Does this mean that someone must get two at one time?
A: Both nighttime garments do not have to be shipped out at the same time. The two-year clock will restart on the date the first garment was supplied.

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

Q: Regarding A6593 (accessories for gradient compression garments or wraps with adjustable straps), it is stated that the quantity and reason for the accessory must be in the medical records. Does this mean that the clinical notes must list each accessory separately and why they are needed in addition to being on the prescription? 
A: The medical records should indicate the accessories needed. This does not have to be from the treating practitioner but could be found within the supplier records from the individual performing the fitting on the beneficiary.

Q: What documentation is needed for lymphedema compression garments?
A: Medical records from the treating physician are required and must include a payable diagnosis. A Standard Written Order (SWO) and Proof of Delivery (POD) are also required. Additional documentation requirements can be found in the Standard Documentation Requirements Article A55426.

• Noridian Medicare website > Policies > Local Coverage Determination (LCD) > Active LCDs

Q: What is the night‑garment payment schedule?
A: Two nighttime garments per body area with payment occurring once every two years are allowable.

Q: Can you clarify how we get paid for an L0650 (lumbar-sacral orthosis) for a beneficiary having surgery?
A: Medical necessity is not established until after surgery. Suppliers are instructed to bill with the ST modifier, and ensure documentation supports medical necessity.

• Noridian Medicare website > Browse by DMEPOS Category > Orthotics

Q: Is there an easier way to locate a refund from an appeal other than searching through Remittance Advice (RA)?
A: Review the Noridian Medicare Portal (NMP), this information will be located under the financials section.

Q: We have been experiencing denials on repairs for capped Group 3 DME items, is there a change in processing repairs?
A: There is no policy change impacting processing of repair claims. Follow the appeals process for claim denials. Refer to the Contact Center for claim specific questions.

Q: Is a new titration study sufficient if the beneficiary has not used PAP therapy for over a year, even though we still have their original 2023 diagnostic study?
A: A new sleep study is not required if it meets Medicare requirements. An SWO and treating physician medical records would be required to restart.

Q: For a prosthetic beneficiary does the K-level need to be documented in the medical records or do the supplier records only need to support the K-level?
A: The beneficiary’s functional level must be supported by the medical records, including an evaluation by the treating practitioner to support the current or potential functional abilities.

Q: For Custom Fabricated Orthoses (L1900, L1904, L1907, L1920, L1940-L1950, L1960, L1970, L1980-L2034, L2036-L2038, L2106-L2108, L2126-L2128, L4631), is the criterion “The condition necessitating the orthosis is expected to be permanent or of long-standing duration (more than six months)” diagnosis-driven or does the physician need to specifically document that the condition is expected to last six months or longer?
A: The criteria is not diagnosis driven alone. The medical records must support the condition and duration of the condition.

Verbal Questions Received During ACM

Q: Do the Global Surgical Package regulations apply to the DME E0747 (osteogenesis stimulator, electrical, non-invasive, other than spinal applications) and E0748 (osteogenesis stimulator, electrical, non-invasive, spinal applications)?
A: Global surgical packages do not apply to DME items: Centers for Medicare & Medicaid Services, Medicare Learning Network (MLN) Booklet – Global Surgery.

Q: An order was written prior to the evaluation that initiated the specialty evaluation. The physical therapy (PT) evaluation was completed and signed by the treating practitioner, and the Detailed Product Description (DPD) was also signed at the same time as the PT evaluation. Is this acceptable, or must the order and DPD be completed after the practitioner reviews and signs off on the specialty evaluation?
A: If a specialty evaluation (such as a PT or occupational therapy (OT) evaluation) is required to establish medical necessity and contains information relied upon to support coverage, the treating practitioner must first review and sign the specialty evaluation, indicating agreement with its findings, before completing the WOPD or SWO. If an order was written prior to the specialty evaluation, PT/OT evaluation and DPD, the order is not valid for coverage purposes. In this situation, a new order and DPD must be completed after the treating practitioner has reviewed and signed the specialty evaluation. The WOPD must be dated on or after the required F2F and the practitioner’s concurrence with the specialty evaluation, and prior to delivery of the item.

Q: The first F2F medical record did not include an addendum. A second medical record was later submitted, and the treating practitioner signed it, but the documentation did not clearly state that it was an “addendum.” Is this acceptable?
A: An addendum does not have to use the specific word “addendum” to be acceptable. However, it must be clearly identifiable as additional documentation to a prior medical record. Best practice is for the treating practitioner to clearly label supplemental documentation as an addendum or otherwise explicitly state that it is intended to supplement a prior note. CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5.

Written Questions Received During ACM

Q: Regarding the CPAP LCD, after the beneficiary has a diagnostic sleep study is another F2F visit required prior to the titration study, if they have their titration study done on a date that is after the diagnostic sleep study?
A: The policy does not require another visit between the diagnostic and titrations studies.

Q: If the SWO states three units for each compression item, can we use the same SWO for the next time they wish to get new garments?
A: If nothing has changed medically, the same SWO can be used for the next refill.

• Noridian Medicare website > Browse by Topic > Documentation

Q: If we bill the SC modifier for bras will the claim be denied?
A: The SC modifier is not a valid modifier for the External Breast Prostheses (EBP) policy. The claim will deny for incorrect modifiers if the SC is appended to EBP claims.

• Noridian Medicare website > Browse by Topic > Modifiers > Modifier Lookup Tool

Q: Are oral anticancer drug (OACD) narratives manually reviewed?
A: If the claim meets the requirements of the associated policy, claims are typically processed without manual intervention.

Q: Regarding OACD narratives, Medicare specifies that "dosage" is required. Does this refer to the drug strength or schedule of dosing? For example: 140 mg or 3xQ12h.
A: The strength must be billed using the appropriate National Drug Code (NDC) and documentation should support. This information may also be added to the narrative for claims processing.

Q: Regarding the guidelines on the six-month insulin requirement prior to new pump start, if a beneficiary is new to the practice and prior records are not available, do we need the formal documents of the full six months before proceeding with service?
A: Medical records supporting coverage criteria must be available upon request. If records are not available, the claim may deny.

• Noridian Medicare website > Browse by Topic > Documentation

Q: Medicare requires documentation be maintained for seven years however, if the qualifying documentation is older than seven years and the provider responds in writing with proof of continued medical necessity, claims should not be denied solely on missing the supporting Medicare qualifying records. For beneficiaries who have been on insulin pump therapy for over 15 years, can pump replacement be supported based on provider attestation of continued medical necessity, even when the original qualifying labs (C-peptide or beta cell antibodies) are no longer available due to the age of the records and repeat labs would not qualify due to long-term therapy?
A: If the original qualifying medical records are unavailable because they are more than seven years old, this should be clearly documented in the current medical record. Medicare does not require suppliers to retain records beyond seven years. When Medicare previously paid for the initial insulin pump, medical necessity for the original equipment is considered to have been established. For beneficiaries who have been on insulin pump therapy for many years, including those exceeding 15 years of use, replacement of the pump may be supported by current documentation demonstrating continued medical necessity.

Q: When we provide L0650 (lumbar-sacral orthosis) to a beneficiary directly after surgery, Medicare denies it stating that it is part of the inpatient stay. Is there a way to get paid?
A: Claims billed to the DME MAC while the beneficiary is inpatient are denied. Items may delivered up to two days prior to discharge, but the date of service is the date of discharge. Follow the appeals process for claim denials.

• Noridian Medicare website > Billing, Claims, and Appeals > Billing Situations > Consolidated Billing

Q: Have there been any changes to billing codes for home sleep studies for 2026?
A: The sleep test is billed to the Part B MAC, not DME. Please reach out to the Part B MAC.

Q: Medicare Advantage plans are required to follow Medicare FFS policy. Does this mean that a DME supplier may provide the home sleep test and the CPAP device and bill the Medicare Advantage plan in the same manner as Medicare Fee‑For‑Service?
A: We are unable to speak to Medicare Advantage Plans and their guidelines.

Q: A beneficiary had commercial insurance in 2025, and our DME company supplied the home sleep test (HST) device and interpretation. The beneficiary is now eligible for Medicare FFS effective March 1, 2026, and requires a CPAP device. Can we provide the CPAP under Medicare FFS?
A: Because the home sleep test was performed and interpreted by the DME supplier while the beneficiary had commercial insurance, it does not meet Medicare’s requirement for an independent diagnostic sleep study. Therefore, the prior HST cannot be used to establish Medicare coverage for CPAP. A Medicare‑acceptable diagnostic sleep study, such as an attended facility‑based PSG or an HST performed and interpreted by an independent qualified provider would be required prior to billing CPAP under Medicare FFS.

Q: Our surgery center no longer supplies E0218 (fluid circulating cold pad with pump) to our beneficiaries who have had knee replacements. Is there a way that we can let the beneficiary purchase it from our office? I do not see a fee schedule for it. Would we use an ABN?
A: LCD L33735 for Cold Therapy states E0218 is not reasonable and necessary. An ABN is in this scenario would be recommended to ensure appropriate shift in liability.

• Noridian Medicare website > Policies > Local Coverage Determination (LCDs) > Active LCDs

Q: Is this accurate regarding shifts in an anniversary date and how this affects Skilled Nursing Facility (SNF) stays and discharge versus equipment delivery?

• The anniversary date can "reset" or shift under specific circumstances:
  • New Date: Once a beneficiary is discharged and returns home, the date of discharge becomes the new anniversary date for all future rental claims.
  • Break in Service: If there is a break in medical necessity or a 60-day interruption in use, a new 13-month rental period and a new anniversary date may be established when service resumes.

A: When the beneficiary is discharged to a payable place of service, the date of discharge may shift to become the new anniversary date.

When service resumes after a 60+ day break in medical need, the beneficiary will need to requalify for the DME item to restart billing with a new initial rental.

• Noridian Medicare website > Billing, Claims, and Appeals > Billing Situations > Break in Need and Break in Billing

Q: It appears that K0861 (group 3 standard power wheelchair) is considered a purchase item; however, the fee schedule is reflecting it as a rental only. Additionally, the motor replacement is also listed as rental only. Is a purchase option available for this repair?
A: Medicare allows a lump‑sum purchase option for complex rehab power wheelchairs only at the time the wheelchair is initially furnished however if that election is not made at initial delivery, the item remains under the capped rental methodology. Replacement motors are treated as repair components and are not eligible for standalone or separate purchases.

• Noridian Medicare website > Browse by Topic > DMEPOS Payment Categories > Capped Rental Items

Q: We are currently receiving denials for prior authorization requests for knee braces L1832 (knee orthosis, adjustable knee joints (unicentric or polycentric) prefabricated (custom fitted)) and L1845 (knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric) prefabricated (custom fitted)) when they are being ordered preoperatively for postoperative care. These braces are intended for use after surgery; however, they are being requested prior to the procedure to ensure continuity of care. Could you please clarify whether these items should only be requested after the surgery has been performed?
A: Prior authorization requests cannot be submitted prior to medical necessity being established. After the surgery is performed, medical necessity is established. Suppliers may bill with the ST modifier in these situations. These claims are subject to prepayment review.

• Noridian Medicare website > Medical Review, ADMC, and Prior Authorization > Prior Authorization

Q: We are billing HCPCS E0935 (continuous passive motion exercise device) for 21 days of use, billing 21 units with a date span of 09/13/2025–10/04/2025. However, the claim is denying as an invalid date range. How should E0935 be billed correctly? Should it be billed as a single date span with multiple units, or in another manner?
A: CPM claims require a date span. The units of service (item 24G) should be the number of days in the date span, including the first and last day. The maximum number of covered days for CPM therapy is 21 days. The surgery date is counted as day one. Billing for more than 21 days may result in denial. Denied claims must follow the appeals process.

• Noridian Medicare website > Browse by DMEPOS Category > Continuous Passive Motion (CPM) Devices > CPM Device Billing Span Dates Calculator

Q: Has there been an update for the diabetic inserts stating that only one pair at a time can be dispensed every four months?
A: Under Medicare Part B, the Therapeutic Shoes for Persons with Diabetes benefit allows per calendar year: One pair of diabetic shoes, and up to three pairs of inserts (depending on shoe type). This has not changed in policy.

Q: For a custom fabricated AFO prescribed for foot drop, when the diagnosis and supporting medical documentation are present, is this sufficient to meet the requirement that the condition is expected to last six months or longer, or must the physician explicitly document the anticipated duration?
A: A diagnosis alone is not sufficient to meet coverage criteria. The medical record must support both the medical necessity for the AFO and that the condition is expected to last six months or longer. While the physician does not have to use specific verbiage, the supporting documentation must demonstrate the chronic or long‑term nature of the condition. If the expected duration is not clear from the records, additional documentation may be needed.

Q: For diabetic shoes and inserts if the Doctor of Podiatric Medicine (DPM) documented the foot exam and the certifying physician did not, would the certifying physician need to sign and concur with the DPM medical records?
A: A certifying physician must complete the Statement of Certifying Physician and show agreement with the podiatrist's medical records.

Q: Can you please clarify whether collagen surgical dressings are covered when used on a routine, full-thickness total knee arthroplasty (TKA) incision from discharge through the post-operative period? The incision is not infected, delayed, or dehisced, and is not classified as an ulcer, though moderate drainage is present and consistent with normal initial incision discharge.
A: Collagen dressing is covered for full thickness wounds (e.g., stage 3 or 4 ulcers), wounds with light to moderate exudate, or wounds that have stalled or have not progressed toward a healing goal. The beneficiary’s medical record must include documentation to support criteria.

Follow-Up Question: To clarify, if the surgeon states the incision was full-thickness and there is moderate drainage the collagen would be covered for all surgical procedures and conditions?
A: Qualifying wounds are defined as surgically created, modified, or debrided wounds. The medical record would need to include documentation supporting coverage criteria.

Q: If providing K0823 (Group 2 standard power wheelchair) as a capped rental and E1032 hardware along with it, can E1032 be billed as upfront purchase?
A: If the wheelchair is provided as a capped rental item, then the hardware cannot be billed as an upfront purchase.

Q: Who do we speak with about retroactive entitlement where the beneficiary does not qualify for equipment received based on Medicare guidelines even though they qualified per the guidelines of the carrier that they were with at the time of service. We are seeing more of these instances, causing beneficiaries to lose medically needed equipment due to Medicare retro entitlement. We just need someone that we can pose this grievance to. It is important that Medicare understands the impact of these retroactive entitlement instances. There is a similar impact when the beneficiary needs repairs or patient-owned equipment paid by another payer prior to Medicare eligibility, when the equipment requires repairs once they are Medicare eligible.
A: Retroactive entitlement is addressed in the Internet Only Manual (IOM), Publication 100‑04, Medicare Claims Processing Manual, Chapter 1, Section 70. Medicare applies current Medicare coverage rules, regardless of prior payer coverage. This issue must be addressed to CMS, who governs these regulations.

Q: For a diagnosis of CSA, can we use only a titration to meet RAD regulation?
A: A titration study by itself is not sufficient to meet RAD coverage requirements for CSA.

Q: If a sleep study does not separate central hypopneas from obstructive apneas, when qualifying CSA, would the beneficiary have to repeat the sleep study with the required information?
A: If the raw data of the sleep test is available, it can be rescored without needing a repeat test.

Q: Is there a way to do a peer-to-peer review when a beneficiary does not meet criteria but the physician is adamant the beneficiary needs it?
A: The Noridian DME MAC does not offer peer-to-peer reviews for DMEPOS claims outside of items that require Prior Authorization or ADMC.

• Noridian Medicare website > Medical Review, ADMC, and Prior Authorization

Q: If a beneficiary is set up under N2, completed re-evaluation and testing, do we continue billing under N2 or change it to the N1 modifier?
A: If there is a change in medical condition, bill the oxygen modifier that reflects the current condition.

• Noridian Medicare website > Browse by DMEPOS Category > Oxygen

Q: What is the NEE portal?
A: NEE stands for Noridian Educational Experience. Like a webinar, most courses offer a CEU upon completion. The benefits to this style of education is that it is a self-paced educational experience where the user clicks through each section and you can sign up and take the courses whenever you please, as opposed to having to sign up for a webinar at a certain scheduled time that may be in conflict with your schedule. It will typically ask a few questions at the end related to the content.

• Noridian Medicare website > Education and Outreach > Noridian Educational Experience

Q: When can we expect to have guidance for continuous glucose monitors (CGMs) moving to the frequent and substantial servicing category? How will we bill for a machine the beneficiary already has?
A: We do not have any guidance at this time. When we have more information, we will begin to educate.

Q: Can another physician within the same practice review the qualifying oxygen test, or is the ordering physician required to review the testing result ordered?
A: The same practitioner must evaluate and order the oxygen.

Q: Under the RAD LCD for CompSA, are criteria 1 and 3 calculated based on total sleep time (TST) for the applicable portion of the study, or only on the time spent at a specific pressure setting where the obstructive apnea‑hypopnea index (AHI) is < 5 and the central apnea‑hypopnea index (CAHI) is ≥ 5?

For example, if during a BiPAP titration with settings at 16/12 for 20 minutes the beneficiary has central apneas, obstructive apneas, mixed apneas, and hypopneas, should the obstructive AHI and CAHI be calculated using only that 20‑minute interval, or based on the relevant total sleep time of the titration study?
A: For CompSA, the numbers must be calculated using the TST during the part of the study where obstructive events are adequately controlled, not based on a brief or isolated pressure interval alone. The obstructive AHI must be < 5, and central events must persist at qualifying levels over an appropriate duration of sleep, as documented by the interpreting physician.

Calculations based solely on a short interval (for example, a single 20‑minute pressure setting) are not sufficient unless the sleep study report clearly documents that the qualifying calculations be derived from an adequate total sleep time and meet all LCD thresholds.

The interpreting physician’s documentation must clearly support that obstructive events were optimally treated and that central apneas/hypopneas remained predominant during the relevant portion of sleep used for calculation.

Q: For oxygen E1390 and E0431,what are the common documentation errors leading to denials on claims? Is repeat testing required for continued coverage? Is hospital testing acceptable and how recent must the testing be? Can I get clarification on the 36-month rental cap rules regarding the E1390 and E0431? After the 36 months on the rental what can still be billed if the E1390 and E0431 are still needed for maintenance or servicing? What documentation or requirements are needed to add portable oxygen?
A: Please refer to the Noridian Medicare website > Medical Review, ADMC, and Prior Authorization > Medical Record Review Results for common documentation errors.

Repeat testing is not required for Group 1. Repeat qualifying test is required for Group II and III.

Testing must occur within two days of discharge.

If a beneficiary was using a stationary concentrator, portable concentrator, or trans-filling equipment during the 36th rental month, Medicare will pay for a maintenance and service visit no more than once every six months, beginning no sooner than six months following the end of the rental period. If the equipment is covered under a warranty that covers labor related to routine/general maintenance and servicing (e.g., inspection, changing filters, cleaning, and calibration), payment for the first visit can be no sooner than six months following the end of that warranty.

A portable oxygen system is covered if the beneficiary is mobile within the home for Groups I and II, and the qualifying blood gas study was performed while at rest (awake) or during exercise. If the only qualifying blood gas study was performed during sleep, portable oxygen will be denied as not reasonable and necessary.

• Noridian Medicare website > Medical Review, ADMC, and Prior Authorization > Medical Record Review Results

Q: Can you confirm compliance requirements for CPAP and BIPAP? If compliance is not met what steps are required to restart coverage? Is a sleep study required after failing compliance? Does the physician note need to state benefit and usage? What objective finding required for a RAD with backup rate? If the beneficiary is due for a replacement after five years will the patient have a new 31-91 compliance period?
A: Refer to PAP and RAD LCD/Policy Articles for specific compliance requirements for each type of machine.

Beneficiaries who fail the initial 12-week trial are eligible to re-qualify for a PAP device but must have both: 1) In-person clinical re-evaluation by the treating practitioner to determine the etiology of the failure to respond to PAP therapy; and, 2) Repeat sleep test in a facility-based setting (Type 1 study). This may be a repeat diagnostic, titration or split-night study.

Yes. A sleep study is required after failing compliance.

Regarding benefit and usage, yes. The following are required 1) In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of OSA are improved; and 2) Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner.

There must be documentation in the beneficiary’s medical record about the progress of relevant symptoms and beneficiary usage of the device up to that time. Failure of the beneficiary to be consistently using the E0470 or E0471 device for an average of four hours per 24-hour period by the time of the re-evaluation (on or after 61 days after initiation of therapy) would represent non-compliant utilization for the intended purposes and expectations of benefit of this therapy.

A new compliance period is not required for replacements.

Q: For Nebulizers and supplies what documentation is required beyond an SWO?
A: Medical records must support the necessity of the items dispensed as outlined in the LCD and policy article. Standard documentation requirements must be met such as proof delivery, refill requirements, as well as documentation of continued use/need.

• Noridian Medicare website > Browse by DMEPOS Category > Nebulizers > Nebulizers and Respiratory Drugs Documentation Checklist

Q: What documentation is required to override a same or similar denial? Is a patient attestation acceptable?
A: A beneficiary attestation alone is not sufficient to overturn a denial. To resolve the denial, follow the appeals process and submit all relevant documentation proving that the item was provided due to a change in medical condition, repair, replacement, loss, theft, etc., whatever the situation may be.

• Noridian Medicare website > Browse by Topic > Same or Similar Chart > Is the Item Same or Similar > Same or Similar: How to Avoid Denial

Q: What documentation is required if prior equipment was lost or damaged? Example: CPAP E0601, BIPAP E0470/E0471, Oxygen E1390/E0431, Nebulizers E0570
A: A new order is required for all items billed to Medicare for payment. Examples of documentation for lost or damaged items may include (not all inclusive): police report, insurance claim report.

• Noridian Medicare website > Browse by Topic > Repairs, Maintenance and Replacement > Replacement

Q: Are electronic signatures fully acceptable on Title 19 or other documents that are required?
A: Electronic signatures that meet Medicare requirements are acceptable.

• Noridian Medicare website > Browse by Topic > Documentation > Signature Requirements

Q: Can you clarify refill documentation timing requirements?
A: Contact with the beneficiary or authorized representative must occur within 30 days prior to the date of service. Suppliers may not automatically refill DME prescriptions.

• Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)

Q: How long must documentation be retained for records on the sleep studies, testing, or POD for DME services?
A: Documentation retention is a supplier standard and is expected to be maintained for a minimum of seven years for Medicare. Suppliers must also stay attuned to any individual state requirements for documentation retention.

• Noridian Medicare website > Browse by Topic > Documentation > Supplier Documentation

Q: In what situations should an ABN be issued for DME equipment and supplies?
A: An ABN should be issued for DME supplies that do not meet Medicare coverage requirements in the item's respective Policy Article and LCD. The purpose of providing an ABN is to notify the beneficiary in writing that the item or service may not be covered and shift the financial liability of an item to the beneficiary before providing that item to the beneficiary.

• Noridian Medicare website > Browse by Topic > Advance Beneficiary Notice of Noncoverage (ABN)

Q: If a beneficiary has an active rental for CPAP, BIPAP, or oxygen, and are admitted to the hospital and subsequently to a rehabilitation facility or nursing home, how do we manage the active rental billing? Do they consider the month they are admitted as not able to bill for the active rental?
A: If the beneficiary is using the items while in the hospital or rehab facility, suppliers would resume billing for the items once they are discharged. If the supplier previously billed six months rental, billing would resume with month seven. Medicare will pay for DME items up until the date of admission.

• Noridian Medicare website > Billing, Claims, and Appeals > Billing Situations > DMEPOS and Inpatient Stays

Q: Will they approve an oxygen purchase or only rental?
A: Oxygen is only billed as a rental.

Q: A beneficiary is supplied with an E0194 (air fluidized bed) but at the time of delivery they have a Medicare Advantage plan. If the beneficiary switches to FFS at any time can the billing restart? Or would the beneficiary need to be on a Group 2 support surface for 30 days prior? If no need for a Group 2, how can we prove that the medical necessity was met prior?
A: The beneficiary must meet the Medicare FFS requirements for Medicare coverage. If the coverage criteria for Medicare FFS coverage is met, billing would begin at rental month one.

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

Q: Will the Monday Live Chats be coming back in 2026?
A: Monday Live Chats have been retired. This decision reflects our commitment to continuously improving your learning experience by offering more flexible, accessible, and impactful educational resources.

In place of the live chats, we encourage you to explore our NEE Portal, a dynamic platform designed to empower your growth through on-demand education, interactive tools, and tailored insights. Additionally, we invite you to participate in our Quarterly ACM, where we share key updates, foster engagement, and provide valuable learning opportunities. We appreciate your continued support and look forward to serving you through these enhanced channels.

Q: If a beneficiary receives 50 catheters on the first of the month, then receives 50 more later in the month, does that take away one refill from the script or two?
A: This is dependent on how the SWO is written. If the order is for 100 catheters, it would be one refill. If the order is for 50 catheters, it would count as two.

Q: Can a beneficiary qualify for a K0006 (heavy duty manual wheelchair) if they weigh 248.5 pounds and the doctor documents why they believe a heavy-duty wheelchair would be necessary?
A: Based on policy requirements the beneficiary would not meet coverage criteria. For claim denials, follow the appeals process with documentation and physician rationale.

• Local Coverage Determination (L33788) – Manual Wheelchair Bases

Q: If a beneficiary has a diagnosis of CSA and not OSA, would a pulse oximetry test qualify, or would titration be needed?
A: Pulse oximetry is not sufficient to establish or treat CSA. A qualifying diagnostic sleep study, and when applicable a titration study, are required for CSA‑related device coverage.

Q: Was the five-minute rule for testing done during sleep removed for oxygen?
A: Yes. That was removed from the policy.

Q: For enteral, what needs to be on the entering Medicare F2F? Does it just need to discuss using and benefiting? Can a visit be within one year?
A: For enteral nutrition, the documentation must support the coverage criteria listed in the policy as well as justification/need of the items provided. Timely documentation is within 12 months of the date of service.

Q: If a beneficiary has been on CPAP, and Medicare paid for the initial 13 months, and the doctor orders a new sleep study, is a new compliance period required due to the new PSG/HST/split sleep study having been done?
A: If the RUL was met, new compliance is not required.

Q: When oxygen is provided for an acute condition, is the correct modifier N2? If after the 60 to 90-day follow-up the diagnosis is still the same, does the modifier need to change, now that the need is ongoing?
A: The modifier is based on how the beneficiary qualifies for oxygen, not based on the length of need. The modifier should reflect current beneficiary condition.

Q: A PAP/RAD beneficiary is transitioning to us for replacement equipment. The RUL has been met, and Medicare paid 13 payments on the equipment more than five years previously. Upon reviewing the studies used for the initial equipment, if we see something in the study that does not meet all the coverage criteria, is a new study required?
A: If medical necessity is not met in the original sleep study a new study should be obtained.

Q: Now that there aren’t any more Monday Live Chat calls, what is the best way to get assistance with questions that may pertain to new orders being set up? We can call the Contact Center, but the representatives may not have all of the knowledge of the experts that were on the Monday call or it may require a call back, or we have to submit our questions to the email, which can take up to 45 days to receive a reply.
A: Besides utilizing the Contact Center, we encourage you to explore our NEE Portal, a dynamic platform designed to empower your growth through on-demand education, interactive tools, and tailored insights.

Additionally, we invite you to participate in our Quarterly ACMs, where we share key updates, foster engagement, and provide valuable learning opportunities. We appreciate your continued support and look forward to serving you through these enhanced channels.

Q: When billing an item with the EY modifier, is an ABN also needed?
A: When the EY modifier is billed because there is no SWO, an ABN would be required if the items would normally be covered by Medicare and financial liability would be shifted to the beneficiary. An ABN would not be required if the lack of an SWO would result in a statutory denial as stipulated by the policy.

• Noridian Medicare website > Browse by Topic > Advance Beneficiary Notice of Noncoverage (ABN)

Q: Is there a five-year rule on backs and cushions for manual and power chairs? If so, are there exceptions other than medical change?
A: In the absence of additional program guidance, the RUL is five years.

Q: For power chairs, does it have to have tilt, and recline to qualify for E2311 (electronics for two or more motors), E2377 (expandable controller) and E2313 (harness)? Or can it qualify with tilt, seat lift, drive, and power legs?
A: The expandable controller (E2377) is allowable when three or more power seating functions/actuators/motors are provided, or when a specialty interface is required, i.e., head control interface (E2327, E2328, E2329, E2330), sip-n-puff interface (E2325), joystick other than a standard proportional joystick (E2312, E2321, E2373), or multi-switch hand control interface (E2322). When two power seating functions/actuators/motors are provided, the E2311 is allowed as well.

• Noridian Medicare website > Browse by DMEPOS Category > Power Mobility Devices (PMDs) > Power Wheelchair Electronics Clarification

Q: Why do Medicare Advantage plans deny coverage stating the beneficiary does not qualify per Medicare guidelines, even if we submit to regular Medicare and attach the approval?
A: We are unable to speak to Medicare Advantage Plans and their guidelines. Suppliers must verify coverage requirements directly with the individual Advantage plan before proceeding.

Q: Is not requiring a therapy evaluation for a replacement power chair a requirement by Advantage plans as well, or only regular Medicare?
A: Medicare Advantage plans are not required to follow Medicare FFS documentation requirements, suppliers must verify coverage requirements directly with the individual Advantage plan before proceeding.

Q: Is there a way to bill for a loaner powerchair while in the process of getting a beneficiary a power chair?
A: Medicare does not allow separate billing for a loaner power wheelchair during the initial rental or while a beneficiary is awaiting approval for a power wheelchair. Medicare only recognizes the use of temporary or loaner equipment during the repair of beneficiary‑owned equipment. In those situations, any loaner provided is considered part of the repair process and is not separately billable.

Additionally, when a power wheelchair is still in the rental period, the supplier is responsible for maintaining the equipment, including repairs, and Medicare does not provide additional payment for loaner equipment during that time.

• Noridian Medicare website > Browse by Topic > Repairs, Maintenance and Replacement > Repairs.

Q: Is there anything in the LCD that states if a beneficiary gets a power chair through insurance, they are able to put their own parts on ( such as batteries) or does the supplier need to install?
A: There is nothing in the LCD that requires a supplier to install parts (such as batteries) or that prohibits a beneficiary from installing their own parts on a Medicare‑covered power wheelchair. Medicare does not regulate mechanical installation practices unless the supplier is billing labor, repair, or service charges, or there is a potential fraudulent billing issue.

Q: We have received denials when the power wheelchair includes tilt, seat elevation (seat lift), power elevating leg rests (ELRs), and drive control, even though this represents more than three power seating functions. Claims are denied unless recline is included. The LCD indicates that three power options are required and does not state that recline must be one of them. Why are these claims denied?
A: The denials may be due to how Medicare defines and counts power seating system actuators, not because recline is specifically required. Coverage of E2311, E2377, and E2313 are allowed only when three or more distinct power seating system actuators are present. Actuators, not power options are what determine eligibility for expandable electronics.

• Local Coverage Determination (L33312) – Wheelchair Seating

Q: If a beneficiary comes in from out of state and gets DME product at the retail store, does this show up as provided to someone out of state and would we be required to hold a DME license required by that state?
A: If the beneficiary physically receives the DME at your in‑state retail location, Medicare generally considers the item furnished at that location. The transaction is not treated as an out‑of‑state delivery solely because the beneficiary resides in another state, and a separate DME license in the beneficiary’s home state is typically not required on that basis alone. Medicare claims must be billed to the appropriate DME MAC jurisdiction based on the beneficiary’s permanent residence.

Q: Can a practitioner sign an SWO if it lists a different practitioner’s name and NPI and if not, is it acceptable for the signing practitioner to cross out the other practitioner’s name and NPI?
A: The signing practitioner’s name and NPI must be on the SWO. If someone other than the treating practitioner’s name and NPI is listed on the SWO, a new or updated order must be obtained to include the signing/ordering practitioner’s information.

• CMS Internet-Only Manuals 100-08, Program Integrity Manual (PIM), Chapter 3, Section 3.3.2.4.

Q: If a medical record has an addendum on it and it is signed as an addendum, can we also submit the original medical record along with the audit if requested?
A: The original medical record along with the addendum must be submitted for review. An addendum does not delete or change any of the existing information in the medical record.

Q: Do funds have to be returned if received before submitting a reopening for a claim?
A: Funds do not need to be returned before requesting a reopening. The MAC will reprocess the claim and issue a new decision and remittance.

Q: For E0471 (RAD) with CSA, what are the requirements if the beneficiary fails the 90-day compliance requirement?
A: Medicare requires reevaluation to establish medical necessity for continued coverage. A clinical reevaluation would be required, as well as clinical rationale for continued use. Also, the treating practitioner documents compliance with use of the device (an average of 4 hours per 24-hour period) and benefits from its use.

• Noridian Medicare website > Policies > Local Coverage Determination (LCD) > Active LCDs > Respiratory Assist Devices L33800

Q: If we have a PAP machine that is still within the five‑year RUL, and the cost to repair it is the same as, or more than, the cost of a replacement, how does a DME provider bill for a replacement when the patient‑owned machine (out of warranty) wasn’t actually repaired?
A: Medicare covers replacement of DME that the beneficiary owns or is purchasing when: 1) the item is lost or irreparably damaged; or, 2) the item is worn beyond repair; or, 3) the patient's medical condition changes such that the current equipment no longer meets the patient's medical need(s). Claims involving replacement equipment necessitated because of wear or a change in the patient's condition must be supported by a current physician's order.

• Noridian Medicare website > Browse by Topic > Repairs, Maintenance and Replacement > Replacement

Follow-Up Question: Will the replacement begin a new 13-month rental period? Also, if the machine was irreparably damaged is a new physician order required for the new 13-month rental period?
A: If there is a break in medical need greater than 60 days, a new capped rental period can begin. A new order is required for replacements; however, new compliance is not required.

Follow-Up Question: What if there has not been a break in medical need, greater than 60 days, for a PAP item that is beneficiary-owned, not under warranty, and before the five-year RUL. The repairs exceed the replaced machine. Can we start a new capped rental period on the replaced machine?
A: If there is a qualifying situation for the replacement, a new capped rental can begin.

Q: If a beneficiary refuses to return equipment or has lost the equipment, are we able to bill them directly for the replacement cost of the equipment? Would an ABN be required in this case? If so, what if the beneficiary refuses to sign an ABN? Is there regulation around this in writing I can point to when I talk to my staff?
A: If Medicare is not expected to pay and the supplier intends to bill the beneficiary, a valid ABN must be issued prior to providing the replacement equipment. Without a proper ABN, the supplier may not bill the beneficiary for an item that Medicare could otherwise consider a covered benefit.
If the beneficiary refuses to sign the ABN, the supplier should document the refusal according to ABN instructions (for example, noting the refusal on the ABN and having staff witness it). A beneficiary’s refusal to sign does not invalidate the ABN, if it was properly delivered and documented before the item was provided.

• Internet Only Manual 100-04 Medicare Claims Processing Manual, Chapter 30, section 50

Q: When providing a replacement CPAP machine, what time frame is the documentation that the beneficiary is using and benefitting from PAP therapy required to be in? Is there a reasonable period, such as one year or six months?
A: The policy does not specify a timeframe for this requirement. Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy.