Commercial

Durable Medical Equipment (DME) and Consumable Medical Supplies
05.00.21x

Policy

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 when all of the above requirements are met. When there is a medical policy addressing a specific item or service, refer to the specific policy for applicable medical necessity criteria.

Refer to Attachment B for a list of items that are benefit contract exclusions and, therefore, not eligible for reimbursement consideration by the Company because they are not considere​d DME and/or an eligible consumable medical supply.
  • 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: Do not report any item in Attachment B that has an N/A under the HCPCS column.

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.

STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written 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 standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file. 

PROOF OF DELIVERY REQUIREMENTS
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 (WHEN APPLICABLE)
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:
  • 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 December 09, 2020​.

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 December 09, 2020.


Coding

CPT Procedure Code Number(s)
N/A

ICD - 10 Procedure Code Number(s)
N/A

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


Policy History

4/1/2021
4/8/2021
05.00.21
Claim Payment Policy Bulletin
Commercial
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No