A claim by a beneficiary or supplier/assignee must be accompanied by the attending physician's prescription or documentation from the attending
physician supporting the need for the equipment. The physician's prescription or other
documentation should include the patient's diagnosis and prognosis, the reason the
equipment is required, and the physician's estimate in months of the duration of the
equipment's need. When prescribing oxygen, written documentation from the physician
must be included, specifying the oxygen flow rate and concentration level and an estimate
of the frequency and duration of oxygen use by the patient. Where any of the above
information is lacking, the carrier will make reasonable inferences from the other
information on the prescription or other documentation. For example, where the attending
physician has prescribed an IPPB machine but has failed to indicate his estimate of
the period of medical necessity, the carrier could readily infer from a diagnosis
of severe pulmonary emphysema that the equipment will be needed long enough to warrant
purchase when the condition is stable, chronic, and non-life threatening. If the information
cannot be inferred and is not obtainable from the carrier's files or from other readily
available sources, the carrier will request the required information from the physician
through written, personal or telephone contact.
Where the information cannot be obtained from the above sources, the carrier will
request the beneficiary or supplier/assignee to obtain from the attending physician
a written statement containing this information.
If, after obtaining the information, a question of medical necessity remains, the
issue is resolved by the carrier's medical staff or other professional consultation.
Where the evidence is insufficient to determine medical necessity, the carrier may
extend or limit development on the individual case by asking the attending physician
to submit his objective findings establishing the severity of the patient's condition
and the patient's immediate and/or long term therapeutic need for the equipment. The
carrier may ask the attending physician for a statement of the therapeutic benefits
he expects the patient to realize from the use of this equipment.
Carriers establish safeguards to assure that payments are not made beyond the last
month of medical necessity or, in the case of purchase, beyond the month which would
complete reimbursement for the item if this comes first. For example, if medical necessity
for an item is estimated by the physician at 2 months but it would require 4 payments
to complete reimbursement, the carrier takes appropriate steps to assure that the
periodic payments will be stopped at the end of the 2-month period.