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.