DME.AD.104.A Medicare: Hierarchy for Applying Coverage Decisions

This document does not list specific covered or excluded DME items; instead it directs that Medicare Advantage DME coverage determinations follow Medicare’s “reasonable and necessary” standard (diagnosis, treatment, or improving function) and be based first on the Medicare Benefit Policy Manual, NCDs, LCDs/LCAs, then proprietary/evidence-based guidance. Reviewers must apply that hierarchy for utilization management and claim edits and follow documentation and limitation rules specified in the cited Medicare manuals and coverage determinations.

"Medicare defines services as reasonable and necessary when they lead to any of the following: Improvement of the functionality of a malformed body member."

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