Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Durable Medical Equipment (DME)
Policy #:MA05.044g

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.


Refer to the following News Articles:

Respiratory Equipment and Related Supplies (updated July 17, 2020)

Waiver of certain requirements during COVID-19 outbreak related to Durable Medical Equipment (DME), prosthetics, orthotics, and supplies for Medicare Advantage members (updated June 30, 2020)

Durable medical equipment (DME) may be eligible for reimbursement consideration by the Company when all of the following criteria are met:
  • The item meets all of the following requirements of Medicare's definition of DME. The item:
    • 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
  • The item is 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.
  • The item will be used in the individual's home.
  • The item is ordered by a physician or other eligible provider.
  • The item is neither considered experimental/investigational nor considered not medically necessary as may be indicated in other policy bulletins.
  • The item is provided by a DME provider or, in limited circumstances, by another eligible provider type as allowed by the Company.

Refer to Attachments A1 and A2 for a list of items that are considered DME and may be covered if other requirements are met.

Refer to Attachment B for a list of items that are not covered and, therefore, not eligible for reimbursement consideration because they do not meet Medicare's definition of DME or are excluded from coverage by Medicare.

NOTE: Do not report any item in Attachment B that has an unspecified code E1399 Durable medical equipment, miscellaneous. These items are not eligible for reimbursement consideration by the Company because they do not meet Medicare's definition of durable medical equipment (DME), or are excluded from coverage by Medicare.

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

As determined by the Company, and based on contracts with durable medical equipment (DME) vendors, DME may be:
  • Rented until the rental cost of the device meets or exceeds the purchase price
  • Always rented on a continuous basis
  • Purchased without a rental period

Authorization of DME items during the rental period is typically valid for a three month period. Continued use beyond the three month period may require additional authorization. Regardless of the rental period, monthly co-pays may be applicable during this rental period.

When there is a policy addressing a specific item or service, refer to the applicable policy.

MEDICARE

This policy is consistent with Medicare's coverage determination. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, durable medical equipment (DME) is covered under the medical benefits of the Company’s Medicare Advantage products when the item meets the definition of DME, as stated in this policy.

Description

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

According to Medicare, the types of equipment that do not meet the definition of DME include, but are not limited to, items that fall into one of the following categories:
  • Equipment used primarily and customarily for a nonmedical purpose (e.g., air conditioners)
  • Equipment used for environmental control or to enhance the individual's environmental setting (e.g., room heaters, humidifiers, dehumidifiers, electric air cleaners)
  • Equipment used to serve comfort or convenience function or is primarily used for the convenience of the person caring for the individual (e.g., elevators, stairway elevators)
  • Equipment that is nonmedical in nature (e.g., physical fitness equipment); first-aid or precautionary-type equipment; self-help devices (e.g., safety grab bars); training equipment

References

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 280.1: Durable medical equipment reference list. [CMS Web site]. 05/05/2005. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=190&ncdver=2&bc=AAAAgAAAAAAAAA%3d%3d&. Accessed June 23, 2017.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 270.1. Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds. [CMS Web site]. Available at:
https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=131&ncdver=3&DocID=270.1&bc=gAAAABgAAAAAAA%3d%3d&. Accessed June 23, 2017.

Evidence of Coverage.

Medicare Claims Processing Manual. Chapter 20 - Durable Medical Equipment, Prosthetics,
Orthotics, and Supplies (DMEPOS). [CMS website]. Revised 3/13/2017. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c20.pdf. Accessed June 23, 2017

Noridian. Noncovered items. [Noridian Web site]. Revised: April 26, 2017. Available at: https://med.noridianmedicare.com/web/jadme/topics/noncovered-items. Accessed June 23, 2017.



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)

Refer to Attachments A1 and A2 for a list of items that meet the definition of durable medical equipment (DME).


Refer to Attachment B for a list of items that do not meet the definition of DME or are excluded from coverage by Medicare.



Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A1: Durable Medical Equipment (DME)
Description: Equipment that Meets the Definition of Durable Medical Equipment (DME)

Attachment A2: Durable Medical Equipment (DME)
Description: Equipment that Meets the Definition of Durable Medical Equipment (DME)

Attachment B: Durable Medical Equipment (DME)
Description: Items that Do Not Meet the Definition of Durable Medical Equipment (DME) or Excluded from Coverage by Medicare







Policy History

REVISIONS FROM MA05.044g
01/01/2020This policy has been identified and updated for the CPT code update effective 01/01/2020.

The following HCPCS codes have been added to this policy: E0787, E2398, K1001, K1002, K1003, and K1004.

REVISIONS FROM MA05.044f
01/01/2019This policy has been identified and updated for the CPT code update effective 01/01/2019.

The following HCPCS have been added to the policy:

E0447: Portable oxygen contents, liquid, 1 month's supply = 1 unit, prescribed amount at rest or nighttime exceeds 4 liters per minute (lpm)

E0467: Home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions

T4545: Incontinence product, disposable, penile wrap, each

This policy has been identified and updated for the CPT code update effective 01/01/2019.

The following HCPCS narratives have been revised in this policy:

A9273

FROM: Hot water bottle, ice cap or collar, heat and/or cold wrap, any type

TO: Cold or hot fluid bottle, ice cap or collar, heat and/or cold wrap, any type

E0218

FROM: Water circulating cold pad with pump

TO: Fluid circulating cold pad with pump, any type

E0483

FROM: High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each

TO: High frequency chest wall oscillation system, includes all accessories and supplies, each


REVISIONS FROM MA05.044e
01/26/2018This version of the policy will become effective 01/26/2018.

The following code was removed from Attachment B as not covered, and added to Attachment A as covered

E0970 No. 2 footplates, except for elevating legrest

The following codes were added to Attachment A as covered
  • E0953 Wheelchair accessory, lateral thigh or knee support, any type including fixed mounting hardware, each
  • E0954 Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot

The following codes were removed from Attachment A as covered and added to Attachment B, as not covered
  • E0603 Breast pump, electric (AC and/or DC), any type
  • E0604 Breast pump, hospital grade, electric (AC and/or DC) any type

The following codes were added to Attachment B as not covered
  • A4210, A4244, A4245, A4246, A4247, A4250, A4490, A4495, A4500, A4510, A4520, A4554, A4575, A4606, A4627, A6530, A6533, A6534, A6535, A6536, A6537, A6538, A6540, A6541, A6542, A6543, A6544, A6549, A9270, A9273, A9275, A9276, A9277, A9278, A9280, A9281, A9282, E0220, E0603, E0604, E0710, E1399

REVISIONS FROM MA05.044d
01/01/2017This policy has been identified for the HCPCS code update, effective 01/01/2017.

Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.

The following HCPCS code has been deleted from this policy:
  • E0628
  • E0967

The following HCPCS narratives have been revised in this policy

CODE: K0552
FROM: Supplies for external drug infusion pump, syringe type cartridge, sterile, each
TO: Supplies for external non-insulin drug infusion pump, syringe type cartridge, sterile, each

CODE: E0627
FROM: Seat lift mechanism incorporated into a combination lift-chair mechanism
TO: Seat lift mechanism, electric, any type

CODE: E0629
FROM: Separate seat lift mechanism for use with patient owned furniture-nonelectric
TO: Seat lift mechanism, non-electric, any type

CODE: E0740
FROM: Incontinence treatment system, pelvic floor stimulator, monitor, sensor and/or trainer
TO: Non-implanted pelvic floor electrical stimulator, complete system

The following HCPCS narratives have been revised and therefore, removed from this policy:

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

REVISIONS FROM MA05.044c
11/30/2016The 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

REVISIONS FROM MA05.044b
07/01/2016The Company’s coverage position for HCPCS Code E0445; Oximeter device for measuring blood oxygen levels noninvasively; has changed from Medically Necessary with criteria, to Not Covered. Therefore, the HCPCS Code E0445 was removed from Attachment A and added to Attachment B.

REVISIONS FROM MA05.044a
01/01/2016The followingHCPCS codes have beendeletedfrom this policy:
  • E0450 Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube)
  • E0460 Negative pressure ventilator; portable or stationary
  • E0461 Volume control ventilator, without pressure support mode, may include pressure control mode, used with non-invasive interface (e.g., mask)
  • E0463 Pressure support ventilator with volume control mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube)
  • E0464 Pressure support ventilator with volume control mode, may include pressure control mode, used with non-invasive interface (e.g., mask)

  • The following HCPCS codes have beenaddedto this policy:
    • E0465 Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)
    • E0466 Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)
    • E1012 Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each

    Existing durable medical equipment documentation requirements, in accordance with Medicare, are now included with examples.

  • REVISIONS FROM MA05.044
    01/01/2015This is a new policy.

    Note: On 12/12/2014 this Notification was revised to include 1/1/2015 HCPCS coding updates.
    • Attachment A: Code A4459 has been added..
    • Codes E0856 and E0986 have revised narratives




    Version Effective Date: 01/01/2020
    Version Issued Date: 01/06/2020
    Version Reissued Date: N/A