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

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

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 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 7 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 5 days before the individual would exhaust their on-hand supply. When there is a policy addressing a specific contact for replenishment or delivery of supply criteria, the information in the specific policy supersedes this general policy.​

If required documentation is not available on file to support a claim at the time of an audit or record request, the DME supplier may be required to reimburse the Company for overpayments.


BILLING REQUIREMENTS

​Do not report any item in Attachment B that has an N/A under the HCPCS column​​​ because the items do not represent DME items.​

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. 

Guidelines

BENEFIT APPLICATION

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

​As determined by the Company, and based on contracts with 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.

Description

Durable medical equipment (DME) is defined 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, portable whirlpool pumps, 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, and heating and cooling plants).
  • Equipment inappropriate for home use: These are items that generally require professional supervision for proper operation (e.g., diathermy machines, medcolator, data transmission devices used for telemedicine purpose, pulse tachometer, 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, ​gauze, dressings/wound covers, antiseptics, and skin preparations).
  • Equipment that is not primarily medical in nature. Equipment that is primarily and customarily used for a nonmedical 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, equipment for safety, speech teaching machines, strollers, stairglides, toileting systems, elevators bathtub lifts, elevators). 
  • Equipment with features of a medical nature that are not required for the individual’s condition (e.g., gait trainer), ​that is, 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). 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 September 15, 2025.

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: September 15, 2025.​

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

Revisions From 05.00.21ai:
11/10/2025
This version of the policy will become effective 11/10/2025. The policy has been updated to clarify polic​y criteria and communicate the addition of items and supplies as Non-Covered because they that do not meet the Company's definition of DME.
​
The following HCPCS codes representing supplies, have been added to attachment B of this policy:
A4212, A4337, A4461, A4483, A4860, A4932, A6219, A6220, A6221, A6222, A6223, A6224, A6228, A6229, A6230, A6231, A6232, A6233, A6266, A6402, A6403, A6404, A6407, A6413, A6441, A6442, A6443, A6444, A6445, A6446, A6447, A6448, A6449, A6450, A6451, A6452, A6453, A6454, A6455, and A6456

Revisions From 05.00.21ah:
10/01/2025This policy has been identified and updated for the HCPCS/CPT code update effective 10/01/2025.

The following HCPCS codes have undergone narrative revisions:
E0765 and E0986 

The following HCPCS codes have been added to attachment A1 of this policy:
E0150, E0658, and E0659

Revisions From 05.00.21ag:
4/01/2025This policy has been identified and updated for the HCPCS/CPT code update effective 4/01/2025.

The following HCPCS codes have undergone narrative revisions:
A4459, E1028, E1801, E1811, E1816, E1818, and E1841

The following HCPCS codes have been added to attachment A1 of this policy:
E1032, E1033, and E1034

The following HCPCS codes have been added to attachment B of this policy:
E1022 and E1023​

Revisions From 05.00.21af:
1/01/2025This policy has been identified and updated for the CPT code update effective 01/01/2025.

The following HCPCS codes have undergone narrative revisions:
E1800, E1805, E1810, E1815, E1825, and E1830

The following HCPCS codes have been added to attachment A1 of this policy:
E1803, E1804, E1807, E1808, E1813, E1814, E1822, E1823, E1826, E1828, and E1829​​

Revisions From 05.00.21ae:
10/01/2024This policy has been identified and updated for the CPT code update effective 10/01/2024​.

HCPCS code E0739 has undergone a narrative revision

The following HCPCS codes have been added to attachment A1 of this policy:
E0469, E0683, E0715, E0716, E0721, E0737, E0743, E0767, E2513

HCPCS code E3200 has been added to attachment A2 of this policy.
​
The following HCPCs codes have been added to attachment B of this policy:
A4543, A4544, A4545, A7021


Revisions From 05.00.21ad:
04/01/2024This policy has been identified and updated for the CPT code update effective 04/01/2024​.

The following HCPCS codes have been added to attachment A1 of this policy:
A4593, A4594, E0468, E0736,  E0738, E0739, E2104, E2298

HCPCs code K1037 has been added to attachment A2 of this policy.
​
The following HCPCs codes have been added to attachment B of this policy:
A9293 and E0152
 
HCPCs code E2001 has had a narrative revision

HCPCs code E2300 has termed and removed from this policy.

Revisions From 05.00.21ac:
01/02/2024This policy has been identified and updated for the CPT code update effective 01/02/2024.

The following HCPCS codes have been added to attachment A of this policy:
A4468, E0530, E0732, E0735, and E2001

The HCPCS code E1301 has been added to Attachment B of this policy

The following HCPCS codes have been removed from attachment A of this policy:
K1001, K1002, K1003, K1006, K1020, and K1021


Revisions From 05.00.21ab:
04/01/2023This policy has been identified and updated for the CPT code update effective 04/01/2023.

HCPCS code A7049 has been added to Attachment A1 of this policy.

The following HCPCS codes have been added to Attachment B of this policy:
A4560 and E0711

Revisions From 05.00.21aa:
10/01/2022​This policy has been identified and updated for the CPT code update effective 10/01/2022.

The following HCPCS codes have been added to Attachment A1 of this policy:
A4596 and E0183

Procedure code E0483 underwent a narrative revision​

Revisions From 05.00.21z:
09/05/2022​
This version of the policy will become effective 9/05/2022. The policy is being updated to address changes in coverage of inhaler/nebulizer accessories and communicate a coding change related to wheelchair transit brackets. 

The following procedure codes, representing holding chambers and spacers for nebulizers and inhalers have been removed from covered items on Attachment A and moved to non-covered items on Attachment B:
S8100 Holding chamber or spacer for use with an inhaler or nebulizer; without mask
S8101 Holding chamber or spacer for use with an inhaler or nebulizer; with mask

The following procedure code has been added to the policy as a non-covered item ​on Attachment B:
A4627 ​Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler

Procedure code K0108 has been removed from the policy. It is addressed in the following medical policies:
  • Wheelchair Options and Accessories
  • Wheelchair Cushions and Seating

Revisions From 05.00.21y:
10/01/2021​This policy has been identified and updated for the CPT code update effective 10/01/2021.

The following HCPCS codes have been added to Attachment A2 of this policy:
K1021 and K1027​

Revisions From 05.00.21x:
04/01/2021​This policy has been identified and updated for the CPT code update effective 04/01/2021.

The following HCPCS code has been added to Attachment A2 of this policy:
K1020: Non-invasive vagus nerve stimulator​

Revisions From 05.00.21w:
02/08/2021​This version of the policy will become effective 02/08/2021.

The following HCPCS codes have been added to this policy in Attachment B: Items that Do Not Meet the Definition of Durable Medical Equipment (DME)​:
A4870: Plumbing and/or electrical work for home hemodialysis equipment
A4890: Contracts, repair and maintenance, for hemodialysis equipment
E0172: Seat lift mechanism placed over or on top of toilet, any type​

​The following narratives have been added to Attachment B: Items that Do Not Meet the Definition of Durable Medical Equipment (DME) represented by NOC code E1399 of this policy​:
Wheelchair accessory, canopies
​Wheelchair accessory, under seat storage 

The following narrative has been removed from Attachment B: Items that Do Not Meet the Definition of Durable Medical Equipment (DME):
Data transmission used for devices for telemedicine purposes​

​HCPCS NOC code E1399 has been added to following narratives in Attachment B: Items that Do Not Meet the Definition of Durable Medical Equipment (DME):​
Lounge bed, (power or manual, not classified as a hospital bed)
​Diathermy machines
Traction units (Designed for facility use)
Irrigating kits
Bathtub lifts
Toilet seats
Toileting systems
Vitrectomy frame/ table/chair​​

Revisions From 05.00.21v:
10​/01/2020This policy has been identified and updated for the CPT code update effective 10/01/2020.

The following HCPCS code has been added to this policy:K1006

The following HCPCS narrative has been revised in this policy:​ E0880​

Revisions From 05.00.21u:
01/01/2020
This 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 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.
11/10/2025
11/10/2025
05.00.21
Claim Payment Policy Bulletin
Commercial
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.