DME/Medicare "5 year rule"

[jennifer8055]

Has anyone that bills for DME products ever heard of Medicare denying a product under the Medicare 5 year rule?  If so, is there any fighting this denial??

This to me has to be one of the silliest things I've ever heard after 20 years.  Medicare HMO plan (Humana) is denying a L4360 for a fracture of the bones on the right foot.  They are stating that the patient had fractures of the same foot less than 5 years ago and was issued the same L4360 by another provider and we will not be paid for the new boot.  If we have an ABN signed by the patient, then we can append that modifier to the claim and they will make the boot patient responsibility, otherwise, we have to eat the cost.

Why can the fact that the patient could have lost the original boot, threw it in the trash, ran over it with a tractor......whatever.....be considered??  I can understand having to wait 1 year between getting replacement DME products, that's what the Medicare guideline is for Diabetic Shoes/Inserts that we issue is.....but 5 years, come on??

[kristin]

I have been doing this as long as you, and I have never heard of such a thing. In fact, with regular Medicare DME, we have had patients get more than one L4360 in a year, due to various reasons, with no problem having them paid. BUT...we are talking about Humana which is bad, and Humana Medicare, which is worse than bad. I pulled my office out of their Medicare plans because they made their own rules, and didn't follow Medicare's rules, and I got sick of it. You could try to go through their appeals process, and keep escalating it if they continue to deny, but I don't know how much success you will have. If they have this spelled out in either the provider's contract, or the patient's benefits manual, you may be SOL.

[jennifer8055]

Kristin -

You said the exact same thing I was thinking when one of my payment posters brought this to my attention.....it's Humana - which is a pain.....but then it's Humana Medicare - which is a HUGE pain in the you know where.  We're going to try and appeal as many levels as we can - but I'm also going to check with the Insurance Commissioner of our state and the head of the TPMA (TN Podiatry Medical Assn.) and see what they say.

Thanks!
Jenn

[Merry]

The 5 year rule is for lot of DME supplies.  Example.. Let's say Medicare supplied an assisted walking device for someone and they subsequently had a stroke so needed a different appliance so that they could be mobile.  If Medicare paid for the first device they will not pay for the second within 5 years. 

[BWM1]

Somebody chime in with more info because I think there is more to this.  You can supply a product to a patient within 5 years IF the product was out of warranty, lost, stolen, etc.  Inside a year its a replacement (see MFR warranty) and from year 2-5 it's a replacement for lost, stolen, or damaged beyond repair and out of warranty.  anyone?