Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Repair and Replacement of Durable Medical Equipment (DME)
Policy #:MA05.062d

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

Repair or replacement of durable medical equipment (DME), or of a medically necessary accessory that is needed for the essential functioning of the DME in relation to the individual's condition, are covered and eligible for reimbursement consideration by the Company as follows:

REPAIR

The repair of a DME item or accessory is covered and eligible for reimbursement consideration when all of the following are met:
  • The DME item itself is covered by Medicare.
  • The DME or accessory is provided by a DME supplier.
  • The cost to repair, rather than replace, the item is justified based on the useful lifetime of the item.
  • The continued use of the DME remains medically necessary.

Labor associated with the repair of DME is eligible for separate reimbursement consideration and is reported using the applicable Health Common Procedure Coding System (HCPCS) Level II code.

REPLACEMENT

The replacement of a previously approved DME item or accessory is covered and eligible for reimbursement consideration when all of the following criteria are met:
  • The DME item itself is covered by Medicare.
  • The replacement DME item or accessory is provided by a DME supplier.
  • The continued use of the DME remains medically necessary for the individual.
  • The DME replacement is not an additional item (e.g., for use when traveling or for an additional residence).
  • The replacement is equivalent to a previously approved DME item.
  • The replacement accessory is for a DME item previously owned/purchased by or for the individual and either one of the following applies:
    • There is a change in the individual's condition that requires a replacement (e.g., weight loss or gain, growth)
    • The DME does not function properly because it has reached or exceeded its life expectancy as determined by the manufacturer.
      • The Company may determine the reasonable useful lifetime of a specific item based on the manufacturer's recommendation or the Food and Drug Administration (FDA)-approved labeling. In the absence of the manufacturer's recommendations or FDA labeling, the Company may determine the reasonable useful lifetime of a specific item, but in no case can it be less than 5 years. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment; however, the Company will cover repair up to the cost of replacement for medically necessary equipment owned by the individual.

Requests for technological advancements or newly released upgrades to equipment, when the original equipment still functions properly and/or there are no significant changes in the individual's condition, are considered not medically necessary and, therefore, not covered.

REPAIR AND REPLACEMENT

If a rental item breaks, it is the individual's responsibility to work with the supplier to replace or repair the item.

If a purchased item breaks and is under warranty, it is the individual's responsibility to work with the manufacturer to replace or repair the item.

If a purchased item breaks and is not under warranty, the Company will provide benefits for the repair or replacement of the item as long as the above criteria are met.

Replacement of equipment which the individual owns or is purchasing or is a capped rental item is covered in cases of loss, or irreparable damage or wear, and when required because of a change in the individual's condition.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination for repair or replacement of DME and supplies. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, repair or replacement of DME and supplies is covered under the medical benefits of the Company’s Medicare Advantage products when the coverage criteria listed in this medical policy are met.

Description

Durable medical equipment (DME) is equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home. Examples of DME include, but are not limited to, wheelchairs, commodes, crutches, and hospital beds.

Medicare defines durable medical equipment (DME) as equipment that:
  • Can withstand repeated use
  • Is primarily and customarily used to serve a medical purpose
  • Generally is not useful to a person in the absence of an illness or injury
  • Is appropriate for use in the home

All requirements of this definition must be met before an item is considered to be DME. However, although an item may be classified as DME, it may not be covered in every instance. Coverage in a particular case is subject to the requirement that the item be necessary and reasonable for the treatment of the individual's illness or injury or to improve the functioning of his or her malformed body member.

Examples of equipment that meets the definition of DME include, but are not limited to:
  • Canes
  • Crutches
  • Walkers
  • Commode chairs
  • Home oxygen equipment
  • Hospital beds
  • Traction equipment
  • Wheelchairs

Repair is the restoration of a DME item or one of its components to correct problems due to wear or damage.

Replacement is the removal and substitution of a DME item or one of its components or supplies that are necessary for proper functioning.
References

Centers for Medicare & Medicaid Services (CMS). Carriers Manual. Part 3 - Claims Process. Chapter II - Coverage and Limitations. 2100.4: Repairs, Maintenance, Replacement, and Delivery. [CMS Web site]. 09/08/05. Available at:https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1725B3.pdf. Accessed August 29, 2017.

Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15 - Covered Medical and Other Health Services. 110.2: Repairs, Maintenance, Replacement, and Delivery. [CMS Web site.] 12/23/05. Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf. Accessed August 29, 2017.

Centers for Medicare and Medicaid Services (CMS). Transmittal #30. Change Request (CR) #3693: Policy for Repair and Replacement of Durable Medical Equipment (DME). [CMS Web site]. 02/18/05. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R30BP.pdf. Accessed August 29, 2017.

Centers for Medicare and Medicaid Services (CMS). Transmittal #3713. Change Request (CR) #9966: Extension of Payment Change for Group 3 Complex Rehabilitative Power Wheelchairs Accessories and Seat and Back Cushions under Section 16005 of the 21st Century Cures Act. [CMS Web site]. 02/03/17. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3713CP.pdf. Accessed August 29, 2017.

Medicare Advantage Evidence of Coverage.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

See Attachment A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Repair and Replacement of Durable Medical Equipment (DME)
Description: A list of Healthcare Common Procedure Coding System (HCPCS) codes with narratives that are specific to repair or replacement







Policy History

MA05.062d
10/01/2018This policy has been updated for the HCPCS code update, effective 10/01/2018.

The following HCPCS code has been termed from the policy:

K0037: High mount flip-up footrest, replacement only, each


MA05.062c
11/01/2017This version of the policy will become effective 11/01/2017.

The intent of this policy remains unchanged, but the policy has been updated to further clarify current benefits. The following HCPCS code has been added to this policy: E2378.

MA05.062b
01/01/2017This policy has been identified for the HCPCS code update, effective 01/01/2017.

The following HCPCS narratives have been revised and therefore, are now added into this policy; in Attachment A:

CODE: E0995
FROM:Wheelchair accessory, calf rest/pad, each
TO: Wheelchair accessory, calf rest/pad, replacement only, each

CODE: E2206
FROM: Manual wheelchair accessory, wheel lock assembly, complete, each
TO: Manual wheelchair accessory, wheel lock assembly, complete, replacement only, each

CODE: E2220
FROM: Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, each
TO: Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement only, each

CODE: E2221
FROM: Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, each
TO: Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each

CODE: E2222
FROM: Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, each
TO: Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each

CODE: E2224
FROM: Manual wheelchair accessory, propulsion wheel excludes tire, any size, each
TO: Manual wheelchair accessory, propulsion wheel excludes tire, any size, replacement only, each

CODE: K0019
FROM: Arm pad, each
TO: Arm pad, replacement only, each

CODE: K0037
FROM: High mount flip-up footrest, each
TO: High mount flip-up footrest, replacement only, each

CODE: K0042
FROM: Standard size footplate, each
TO: Standard size footplate, replacement only, each

CODE: K0043
FROM: Footrest, lower extension tube, each
TO: Footrest, lower extension tube, replacement only, each

CODE: K0044
FROM: Footrest, upper hanger bracket, each
TO: Footrest, upper hanger bracket, replacement only, each

CODE: K0045
FROM: Footrest, complete assembly
TO: Footrest, complete assembly, replacement only, each

CODE: K0046
FROM: Elevating legrest, lower extension tube, each
TO: Elevating legrest, lower extension tube, replacement only, each

CODE: K0047
FROM: Elevating legrest, upper hanger bracket, each
TO: Elevating legrest, upper hanger bracket, replacement only, each

CODE: K0050
FROM: Ratchet assembly
TO: Ratchet assembly, replacement only

CODE: K0051
FROM: Cam release assembly, footrest or legrest, each
TO: Cam release assembly, footrest or legrest, replacement only, each

CODE: K0052
FROM: Swingaway, detachable footrests, each
TO: Swingaway, detachable footrests, replacement only, each

CODE: K0069
FROM: Rear wheel assembly, complete, with solid tire, spokes or molded, each
TO: Rear wheel assembly, complete, with solid tire, spokes or molded, replacement only, each

CODE: K0071
FROM: Front caster assembly, complete, with pneumatic tire, each
TO: Front caster assembly, complete, with pneumatic tire, replacement only, each

CODE: K0072
FROM: Front caster assembly, complete, with semipneumatic tire, each
TO: Front caster assembly, complete, with semi-pneumatic tire, replacement only, each

CODE: K0077
FROM: Front caster assembly, complete, with solid tire, each
TO: Front caster assembly, complete, with solid tire, replacement only, each

CODE: K0098
FROM: Drive belt for power wheelchair
TO: Drive belt for power wheelchair, replacement only

MA05.062a
11/30/2016This policy was updated with the following revisions;

The following HCPCS codes have been removed from Attachment A2 of this policy:

K0017 - Detachable, adjustable height armrest, base, replacement only, each
K0018 - Detachable, adjustable height armrest, upper portion, replacement only, each

MA05.062
10/14/2015 The policy has been reviewed and reissued to communicate the Company’s continuing position on repair or replacement of DME and supplies.
01/01/2015This is a new policy.

Note: On 12/18/2014 this Notification was revised to include 1/1/2015 HCPCS coding updates. Attachment A of this policy was updated as follows:
  • Codes A4602 has been added.
  • Code A4601 has a revised narrative.






Version Effective Date: 10/01/2018
Version Issued Date: 10/01/2018
Version Reissued Date: N/A