Durable medical equipment (DME) may be eligible for reimbursement consideration by the Company when all of the following criteria are met:
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 considered DME and/or an eligible consumable medical supply.
- 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.
NOTE: Do not report any item in Attachment B that has an N/A under the HCPCS column.
- 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
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.
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.