Notification



Notification Issue Date:



Claim Payment Policy


Title:Durable Medical Equipment (DME) and Consumable Medical Supplies

Policy #:05.00.21t

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

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.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.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

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

Durable medical equipment (DME) may be eligible for reimbursement consideration by the Company when all of the following criteria are met:
  • The individual has the benefit for the item.
  • The item meets the Company's definition of DME.
  • The item is neither considered experimental/investigational nor considered not medically necessary by the Company.
  • The item is considered medically necessary for the treatment of, or as an aid in the treatment of, a medical or surgical condition.
  • The item is ordered by an eligible professional provider.
  • 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 benefit contract exclusions and, therefore, not covered because they are not considered DME and or an eligible consumable medical supplies.
  • Table I: Comfort and convenience items
  • Table II: Equipment used for environmental control
  • Table III: Equipment inappropriate for home use
  • Table IV:Consumable medical supplies
  • Table V: Equipment that is not primarily medical in nature
  • Table VI: Equipment with features of a medical nature that are not required for an individual’s condition
  • Table VII Duplicate equipment for use when traveling or for an additional residence, whether or not prescribed by a professional provider
  • Table VIII: Services not primarily billed for by a provider
  • Table IX: Modifications to vehicles, dwellings, and other structures


NOTE: For any item in Attachment B that has a N/A under the HCPCS column, do NOT report the item, as these items are not eligible for reimbursement consideration because they do not meet the Company's definition of durable medical equipment (DME).

Inclusion of a code in this policy does not guarantee reimbursement. Eligibility, benefits limitations, medical necessity, exclusions, precertification/referral requirements, provider contracts, and applicable policies apply. Coverage of DME varies by product and/or group contract. Therefore, individual member benefits must be verified.

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.

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.
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
  • Purchased without a rental period
  • Always rented on a continuous basis

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

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, DME is covered under the medical benefits of most Company products. Individual benefits must be verified as some contracts exclude DME.

Description

Company benefit contracts define durable medical equipment (DME) as 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, is appropriate for use in the home, and is prescribed by a professional provider.

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

According to Company benefit contracts, the types of equipment that do not meet the definition of DME include, but are not limited to:
  • Comfort and convenience items: These are incidental items that generally serve no medical purpose (e.g., massage devices, telephone alert system, bed-wetting alarms, ramps).
  • Equipment used for environmental control: These are items that are generally used to alter environmental conditions, temperatures or humidity (e.g., air conditioners, dehumidifiers, air cleaners, portable room heaters).
  • Equipment inappropriate for home use: These are items that generally require professional supervision for proper operation (e.g., diathermy machines, medcolator, translift chairs, traction units).
  • Consumable medical supplies other than supplies that are an integral part of the DME item (i.e., required for the DME to function). Specifically, this means equipment that is not durable or is not a component of the DME (e.g., lamb’s wool pads; ace bandages; face masks (surgical); disposable gloves, sheets and bags, bandages, antiseptics, and skin preparations).
  • Equipment that is not primarily medical in nature. Equipment that is primarily and customarily used for a non-medical purpose may or may not be considered medical in nature. This is true even though the item may have some medically related use (e.g., exercise equipment, including the MotoMed Movement Therapy System; equipment for safety; speech teaching machines; stairglides; elevators; bathtub lifts).
  • Equipment with features of a medical nature that are not required for the individual’s condition (e.g., gait trainer), i.e., the therapeutic benefits of the item cannot be clearly disproportionate to its cost if there exists a medically appropriate and realistically feasible alternative item that serves essentially the same purpose.
  • Duplicate equipment for use when traveling or for an additional residence, whether or not prescribed by a professional provider.
  • Services not primarily billed for by a provider (e.g., delivery, set-up, installation, labor, or service of rented or purchased equipment).
  • Modifications to vehicles, dwellings, and other structures, including but not limited to the purchase and/or installation of elevators and/or stair lifts. This includes any alterations made to a vehicle, dwelling, or other structure to accommodate an individual’s disability or any modification made to a vehicle, dwelling, or other structure to accommodate a DME item, such as customization to a wheelchair.

References


Company Benefit Contracts.

Centers for Medicare & Medicaid Services (CMS). Coverage Issues - Durable Medical Equipment. [CMS Web site]. Available at: http://www.cms.hhs.gov/manuals/downloads/Pub06_PART_60.pdf. Accessed January 2, 2018.

Centers for Medicare & Medicaid Services (CMS). Medicare National Coverage Determinations Manual. Chapter 1, Part 4: Coverage Determinations. [CMS Web site]. 08/02/2013. Available at: http://www.cms.gov/manuals/downloads/ncd103c1_Part4.pdf. Accessed January 2, 2018.




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 Company's definition of durable medical equipment (DME).

Refer to Attachment B for a list of items that do not meet the Company's definition of DME.


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

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

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

Attachment B: Durable Medical Equipment (DME) and Consumable Medical Supplies
Description: Items that Do Not Meet the Definition of Durable Medical Equipment (DME)


 Policy: 00.01.25at:PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services

 Policy: 00.10.01ab:Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers

 Policy: 05.00.01l:Pneumatic Compression Therapy Devices

 Policy: 05.00.05k:Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes

 Policy: 05.00.08e:Continuous Passive Motion (CPM) Devices in the Home Setting

 Policy: 05.00.12g:Manual Wheelchairs

 Policy: 05.00.14j:High-Frequency Chest Wall Oscillation Devices

 Policy: 05.00.15p:Nebulizers and Inhalation Solutions

 Policy: 05.00.29k:Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)

 Policy: 05.00.31e:Pulse Oximetry Devices in the Home Setting

 Policy: 05.00.32i:Speech and Non-Speech Generating Devices

 Policy: 05.00.38j:Negative-Pressure Wound Therapy (NPWT) Systems

 Policy: 05.00.42g:Patient Lifts

 Policy: 05.00.43f:Seat Lift Mechanisms

 Policy: 05.00.44k:Repair and Replacement of Durable Medical Equipment (DME)

 Policy: 05.00.48j:Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum

 Policy: 05.00.54g:Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices

 Policy: 05.00.55i:Wheelchair Cushions and Seating

 Policy: 05.00.56i:Hospital Beds and Accessories

 Policy: 05.00.58l:Home Oxygen Therapy

 Policy: 05.00.60g:Pressure-Reducing Support Surfaces

 Policy: 07.07.02j:Ultraviolet Light Therapy for the Treatment of Dermatological Conditions

 Policy: 08.00.17g:Total Parenteral Nutrition (TPN) / Intradialytic Parenteral Nutrition (IDPN) / Intraperitoneal Parenteral Nutrition (IPN)

 Policy: 10.06.01k:Speech Therapy

 Policy: 11.00.06j:Treatment of Obstructive Sleep Apnea (OSA) and Primary Snoring

 Policy: 11.14.21g:Microprocessor-Controlled Prostheses for Lower-Extremity Amputees

 Policy: 05.00.30l:Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices (Independence Administrators)


Policy History

REVISIONS FROM 05.00.21t
01/01/2019
    This policy has been identified and updated for the CPT/HCPCS 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

    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 05.00.21s
05/22/2018
This version of the policy will become effective 05/22/2018.
  • The following HCPCS codes have been added to Attachment A1 of this policy:
    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

    E0574 Ultrasonic/electronic aerosol generator with small volume nebulizer
  • The following HCPCS codes have been removed from Attachment A1 of this policy:
    E0188 Synthetic sheepskin pad

    E0189 Lambswool sheepskin pad, any size
  • The following HCPCS codes have been removed from Attachment A2 of this policy:
    K0070 Rear wheel assembly, complete with pneumatic tire, spokes or molded, replacement only, each

    S1040 Cranial remolding orthosis, orthotic pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)
  • The following HCPCS codes have been added to Attachment B (Not Covered) of this policy:
    A4244, A4246, A4247, A4248, A4360, A4520, A4553, A4554, A4674, A4927, A4928, A4930, A4931, A6000, A6250, A9273, E0188, E0189, T4521, T4522, T4523, T4524, T4525, T4526, T4527, T4528, T4529, T4530, T4531, T4532, T4533, T4534, T4335, T4536, T4537, T4338, T4539, T4540, T4541, T4542, T4543, T4544, A9273
  • The following HCPCS codes have been removed from Attachment B of this policy, as not covered:
    E0574 Ultrasonic/electronic aerosol generator with small volume nebulizer

    L8510 Voice Amplifier


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2019
Version Issued Date: 01/10/2019
Version Reissued Date: N/A

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Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.