3. Has the Reasonable Useful Lifetime (8 years) expired?
Yes No
A new 15-month rental period may begin. A new order is required along with a narrative and proper modifiers. Also refer to the specific guidelines outlined in the LCD/PA.
You may also refer to the Claim Narratives Chart
for guidance for proper narratives.
4. Are you seeking a new 15-month rental period due to a change in the supplier?
Yes No
Change in Supplier does not begin a new 15-month rental period whether the rental period has completed or not.
Change in Supplier during the 15-month rental period: The new supplier is entitled to the balance remaining on the 15-month rental period.
Change in Supplier after the 15-month rental period: The supplier that collects the last month of rental (i.e., the 15th month) is responsible for ensuring that the beneficiary has a pump for as long as it is medically necessary and for maintenance and servicing of the pump during the period of medical necessity.
Refer to the DME Supplier Manual, Chapter 5, for more information.
5. Was the equipment lost, stolen, or irreparably damaged in a specific incident?
Yes No
A new 15-month rental period may begin. Refer to the DME Supplier Manual for information about replacement and documentation needed for replacement.
6. Was the pump rented or purchased?
Rented Purchased
7. Has the 15-month rental limit been reached?
Yes No
8. Has the attending physician changed the prescription between parenteral and enteral nutrients?
Yes No
A new 15-month rental period may begin. A new order is required along with a narrative and proper modifiers. Also refer to the specific guidelines outlined in the LCD/PA.
You may also refer to the Claim Narratives Chart for guidance for proper narratives.
9. Did the medical necessity for the use of the pump end for two consecutive months?
Yes No
A new 15-month rental period may begin. A new order is required along with a narrative and proper modifiers. Also refer to the specific guidelines outlined in the LCD/PA.
You may also refer to the Claim Narratives Chart for guidance for proper narratives.
A new 15-month rental period may not begin. Please refer to the appropriate Policy Article for specific information on when a new 15-month rental period would begin.
8. Did the medical necessity for the use of the pump end for two consecutive months?
Yes No
A new 15-month rental period may begin. A new order is required along with a narrative and proper modifiers. Also refer to the specific guidelines outlined in the LCD/PA.
You may also refer to the Claim Narratives Chart for guidance for proper narratives.
A new 15-month rental period may not begin. Please refer to the appropriate Policy Article for specific information on when a new 15-month rental period would begin.
7. Has the attending physician changed the prescription between parenteral and enteral nutrients?
Yes No
A new 15-month rental period may begin. A new order is required along with a narrative and proper modifiers. Also refer to the specific guidelines outlined in the LCD/PA.
You may also refer to the Claim Narratives Chart for guidance for proper narratives.
8. Did the medical necessity for the use of the pump end for two consecutive months?
Yes No
A new 15-month rental period may begin. A new order is required along with a narrative and proper modifiers. Also refer to the specific guidelines outlined in the LCD/PA.
You may also refer to the Claim Narratives Chart for guidance for proper narratives.
A new 15-month rental period may not begin. Please refer to the appropriate Policy Article for specific information on when a new 15-month rental period would begin.