Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
Policy #:MA05.028d

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 June 11, 2020)

Subject to the terms and conditions of the applicable durable medical equipment (DME) provider agreement, the DME items listed in the Coding Table of this policy are not subject to a rental-to-purchase maximum and are, therefore, rented on a continuous basis, when medical necessity is established.

DME items that are not subject to a rental to purchase maximum must meet the following criteria:
  • The length of usage is expected to be greater than 15 months.
  • Equipment is either:
    • Life-sustaining, or
    • Requires specialized/frequent maintenance and service

FACE-TO-FACE REQUIREMENTS

As a condition for payment, a professional provider must have a face-to-face examination with the individual for whom the item is ordered that meets all of the following requirements:

The treating professional provider must have an in-person examination with the individual within the six (6) months prior to the date of the written order prior to delivery.

  • This examination must document that the individual was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.

A new face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required:
  • For all claims for purchases or initial rentals
  • When there is a change in the prescription for the accessory, supply, drug, etc.
  • If periodic prescription renewal required per medical policy
  • When an item is replaced
  • When there is a change in the supplier
  • When required by state law

In this policy the specified item(s) is (are):

CodeNarrative
E0194Air fluidized bed
E0424Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0431Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing
E0433Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and contents gauge.
E0434Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing
E0439Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
K0606Automatic external defibrillator, with integrated electrocardiogram analysis, garment type

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.

Documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual’s clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.

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

Claims for this service submitted on behalf of the Company's Medicare Advantage members are reimbursed in accordance with this policy. The Company's payment methodology may differ from 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) items that are not subject to a rental-to-purchase maximum and are, therefore, rented on a continuous basis are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.
Description

Durable medical equipment (DME) is generally rented until the rental cost of the device meets the purchase price. However, the DME items listed in the Coding Table of this policy are not subject to a rental-to-purchase maximum and are, therefore, rented on a continuous basis as determined by the Company.
References

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c20.pdf

Company Provider Contracts.

Evidence of Coverage.

Medicare NHIC, Corp. Chapter 10: Durable Medical Equipment. http://www.medicarenhic.com/viewdoc.aspx?id=3254.


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)

E0194 Air fluidized bed


E0328 Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress

E0329 Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress

E0424 Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing

E0431 Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing

E0433 Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and contents gauge.

E0434 Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing

E0439 Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing

E0457 Chest shell (cuirass)

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)
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

E0500 IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source

E1390 Oxygen concentrator, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate

E1391 Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each

E1392 Portable oxygen concentrator, rental

K0455 Infusion pump used for uninterrupted parenteral administration of medication, (e.g., Epoprostenol or Treprostinol)

K0606 Automatic external defibrillator, with integrated electrocardiogram analysis, garment type

K0738 Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders, includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing



Revenue Code Number(s)

N/A

Coding and Billing Requirements






Policy History

REVISIONS FROM MA05.028d:
01/01/2019This policy has been identified and updated for the CPT code update effective 01/01/2019.

The following HCPCS code has been added to the policy:

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


REVISIONS FROM MA05.028c:
07/01/2016The following HCPCS code has been deleted from this policy:

E0445 Oximeter device for measuring blood oxygen levels non-invasively.

REVISIONS FROM MA05.028b:
04/01/2016This policy will become effective on 04/01/2016.

Revised policy number MA05.028b was issued as a result of a coding update.

The following HCPCS codes have been added to this policy per clinical/reimbursement review:

E0433, E0500, K0455

The following HCPCS codes have been deleted from this policy per clinical/reimbursement review:

E0471, E0472, E0482, E0630, E0935, E0936, E2402

This policy has been identified for the annual CPT code update, effective 01/01/2016:

The following codes have been deleted from this policy:

E0450, E0460, E0461, E0463, E0464

The following codes have been added to this policy:

E0465, E0466

On 1/12/2016 language was revised in the Policy section of the document in Notification. Rental to purchase maximum criteria was added and the list of Face to Face codes was updated.

REVISIONS FROM MA05.028a:
06/01/2015The following HCPCS code has been added to this policy:

K0606: Automatic external defibrillator, with integrated electrocardiogram analysis, garment type

REVISIONS FROM MA05.028:
01/01/2015This is a new policy issued as a result of the development of a separate book of Medicare Advantage policy and based on Company Claim Payment policy 05.00.48.




Version Effective Date: 01/01/2019
Version Issued Date: 01/04/2019
Version Reissued Date: N/A