Page 125 - Medicare Benefit Policy Manual

medical information available to the DME MAC will be sufficient to establish that the
equipment serves this purpose.

2. Reasonableness of the Equipment

Even though an item of DME may serve a useful medical purpose, the DME MAC or
A/B MAC (A) must also consider to what extent, if any, it would be reasonable for the
Medicare program to pay for the item prescribed. The following considerations should
enter into the determination of reasonableness:

1. Would the expense of the item to the program be clearly disproportionate to
the therapeutic benefits which could ordinarily be derived from use of the
equipment?

2. Is the item substantially more costly than a medically appropriate and
realistically feasible alternative pattern of care?

3. Does the item serve essentially the same purpose as equipment already
available to the beneficiary?

3. Payment Consistent With What is Necessary and Reasonable

Where a claim is filed for equipment containing features of an aesthetic nature or features
of a medical nature which are not required by the patient’s condition or where there exists
a reasonably feasible and medically appropriate alternative pattern of care which is less
costly than the equipment furnished, the amount payable is based on the rate for the
equipment or alternative treatment which meets the patient’s medical needs.

The acceptance of an assignment binds the supplier-assignee to accept the payment for
the medically required equipment or service as the full charge and the supplier-assignee
cannot charge the beneficiary the differential attributable to the equipment actually
furnished.

4. Establishing the Period of Medical Necessity

Generally, the period of time an item of durable medical equipment will be considered to
be medically necessary is based on the physician’s estimate of the time that his or her
patient will need the equipment. See the Medicare Program Integrity Manual, Chapters 5
and 6, for medical review guidelines.

D. Definition of a Beneficiary’s Home

For purposes of rental and purchase of DME a beneficiary’s home may be his/her own
dwelling, an apartment, a relative’s home, a home for the aged, or some other type of
institution (such as an assisted living facility, or an intermediate care facility for