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MA PPO Host - Claim Payment Policy Bulletin

Durable Medical Equipment (DME)
MA05.044s

Policy

Durable medical equipment (DME) may be eligible for reimbursement consideration by the Company when all of the following criteria are met:
  • The item meets all of the following requirements of Medicare's definition of DME. The item:
    • Can withstand repeated use
    • Is primarily and customarily used to serve a medical purpose
    • Generally is not useful to a person in the absence of an illness or injury
    • Is appropriate for use in the home
  • The item is necessary and reasonable for the treatment of the individual's illness or injury or to improve the functioning of his or her malformed body member.
  • The item will be used in the individual's home.
  • The item is ordered by a physician or other eligible provider.
  • The item is neither considered experimental/investigational nor considered not medically necessary as may be indicated in other policy bulletins.
  • 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 not covered and, therefore, not eligible for reimbursement consideration by the Company because they do not meet Medicare's definition of DME or are excluded from coverage by Medicare​ (e.g. face masks (surgical), safety grab bars​, antiseptics, and skin preparations). 

NOTE: Do not report any item in Attachment B that has an N/A under the HCPCS column​​​.

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:

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
  • Always rented on a continuous basis
  • Purchased without a rental period
When there is a policy addressing a specific item or service, refer to the applicable policy.

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) is covered under the medical benefits of the Company’s Medicare Advantage products when the item meets the definition of DME, as stated in this policy.

Description

Medicare defines durable medical equipment (DME) as equipment that:
  • Can withstand repeated use
  • Is primarily and customarily used to serve a medical purpose
  • Generally is not useful to a person in the absence of an illness or injury
  • Is appropriate for use in the home
All requirements of this definition must be met before an item is considered to be DME. However, although an item may be classified as DME, it may not be covered in every instance. Coverage in a particular case is subject to the requirement that the item be necessary and reasonable for the treatment of the individual's illness or injury or to improve the functioning of his or her malformed body member.

Examples of equipment that meets the definition of DME include, but are not limited to:
  • Canes
  • Crutches
  • Walkers
  • Commode chairs
  • Home oxygen equipment
  • Hospital beds
  • Traction equipment
  • Wheelchairs
According to Medicare, the types of equipment that do not meet the definition of DME include, but are not limited to, items that fall into one of the following categories:
  • Equipment used primarily and customarily for a nonmedical purpose (e.g., air conditioners)
  • Equipment used for environmental control or to enhance the individual's environmental setting (e.g., room heaters, humidifiers, dehumidifiers, electric air cleaners)
  • Equipment used to serve comfort or convenience function or is primarily used for the convenience of the person caring for the individual (e.g., elevators, stairway elevators)
  • Equipment that is nonmedical in nature (e.g., physical fitness equipment); first-aid or precautionary-type equipment; self-help devices (e.g., safety grab bars); training equipment

References

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 280.1: Durable medical equipment reference list. [CMS Web site]. 05/05/2005. Available at: http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=190&ncdver=2&bc=AAAAgAAAAAAAAA==&. Accessed December 09, 2020.

Evidence of Coverage.

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 December 09, 2020.

Noridian. Noncovered items. [Noridian Web site]. Revised: April 26, 2017. Available at: https://med.noridianmedicare.com/web/jadme/topics/noncovered-items. 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 definition of durable medical equipment (DME).

Refer to Attachment B for a list of items that do not meet the definition of DME or are excluded from coverage by Medicare.
Revenue Code Number(s)
N/A

Cross Reference

Policy History

Revisions From MA05.044​s:
1/01/2025This policy has been identified and updated for the HCPCS/CPT code update effective 1/01/20245.

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 MA05.044r:
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 MA05.044q:
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 MA05.044p:
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 MA05.044o:
​01/01/2024
​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.​
10/09/2023
This version of the policy will become effective 10/09/2023. The policy is being updated to address changes in coverage of the following DME items associated with wheelchairs and wheelchair accessories. ​ The changes are a result of revisions in CMS coverage.

The Company’s coverage position has changed from non-covered to eligible for the following HCPCS codes:

E2300: ​Wheelchair accessory, power seat elevation system, any type

K0830: ​Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds

K0831​: ​Power wheelchair, group 2 standard, seat elevator, captains chair, patient weight capacity up to and including 300 pounds

Revisions From MA05.044n:
04/01/2023
This 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 MA05.044m:
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 MA05.044l:
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 and nebulizer accessories. ​ 

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

On attachment B procedure code A9280 has had a narrative revision
​From: Telephone alert system
To: Alert or alarm device, not otherwise classified

Revisions From MA05.044k:
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 MA05.044j:
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 MA05.044i:
02/28/2021​​This version of the policy will become effective 02/08/2021.

The following narratives representing items considered Non-DME have been added to this policy in Attachment B: Items that Do Not Meet the Definition of Durable Medical Equipment (DME) or Excluded from Coverage by Medicare represented by NOC code E1399​ :
​Wheelchair accessory, canopies
Wheelchair accessory, under seat storage

The following HCPCS codes have been removed from Attachment B: Items that Do Not Meet the Definition of Durable Medical Equipment (DME) or Excluded from Coverage by Medicare because they are not DME, relevant to the policy and/or we have other policies that speak to the item:
A4490, A4495, A4500, A4510, A4520, A4554, A4575, A4606, A6530, A6533, A6534, 
A6535, A6536, A6537, A6538, A6540, A6541, A6542, A6543, A6544, A6549, A9270, A9275, A9276, A9277, A9278, and A9282

The the HCPCS NOC code E1399 has been removed from following narratives in Attachment B: Items that Do Not Meet the Definition ofDurable Medical Equipment 
(DME) or Excluded from Coverage by Medicare​ of this policy:
Ai​r Cleaners
Air Conditioners
American bidet toilet seat
American Sonoid and massage foam cushion pad
Bed wetting alarms
Carafe
Car seats
Car beds
Carrying cases or wall mounting hardware for the AED
Devices for Data transmission
Dehumidifiers
Devices for telemedicine purposes
Disposable sheets and bags
Ear plugs
Electronically controlled heating and cooling units for pain relief
Elevators
Emesis basin
Face mask (surgical)
Feeding chairs
Heating and cooling plants
Ice pack
Massage devices
Medcolator
Portable room heaters
Pulse tachometer
Ramps
Sauna baths
Silverware/utensils
Speech teaching machines
Stairglides
Standing table
Strollers
Telephone arm alert system​​

Revisions From MA05.044h:
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 MA05.044g:
01/01/2020This 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 MA05.044f:
01/01/2019This policy has been identified and updated for the CPT 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

This policy has been identified and updated for the CPT code update effective 01/01/2019.

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 MA05.044e:
01/26/2018This version of the policy will become effective 01/26/2018.

The following code was removed from Attachment B as not covered, and added to Attachment A as covered

E0970 No. 2 footplates, except for elevating legrest

The following codes were added to Attachment A as covered
  • 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
The following codes were removed from Attachment A as covered and added to Attachment B, as not covered
  • E0603 Breast pump, electric (AC and/or DC), any type
  • E0604 Breast pump, hospital grade, electric (AC and/or DC) any type
The following codes were added to Attachment B as not covered
  • A4210, A4244, A4245, A4246, A4247, A4250, A4490, A4495, A4500, A4510, A4520, A4554, A4575, A4606, A4627, A6530, A6533, A6534, A6535, A6536, A6537, A6538, A6540, A6541, A6542, A6543, A6544, A6549, A9270, A9273, A9275, A9276, A9277, A9278, A9280, A9281, A9282, E0220, E0603, E0604, E0710, E1399

Revisions From​ MA05.044d:
01/01/2017This policy has been identified for the HCPCS code update, effective 01/01/2017.

Inclusion of a policy in a Code Update memo does not imply that a full review of the policy was completed at this time.

The following HCPCS code has been deleted from this policy:
  • E0628
  • E0967
The following HCPCS narratives have been revised in this policy

CODE: K0552
FROM: Supplies for external drug infusion pump, syringe type cartridge, sterile, each
TO: Supplies for external non-insulin drug infusion pump, syringe type cartridge, sterile, each

CODE: E0627
FROM: Seat lift mechanism incorporated into a combination lift-chair mechanism
TO: Seat lift mechanism, electric, any type

CODE: E0629
FROM: Separate seat lift mechanism for use with patient owned furniture-nonelectric
TO: Seat lift mechanism, non-electric, any type

CODE: E0740
FROM: Incontinence treatment system, pelvic floor stimulator, monitor, sensor and/or trainer
TO: Non-implanted pelvic floor electrical stimulator, complete system

The following HCPCS narratives have been revised and therefore, removed from this policy:

CODE: E0995
FROM:Wheelchair accessory, calf rest/pad, each
TO: Wheelchair accessory, calf rest/pad, replacement only, each

CODE: E2206
FROM: Manual wheelchair accessory, wheel lock assembly, complete, each
TO: Manual wheelchair accessory, wheel lock assembly, complete, replacement only, each

CODE: E2220
FROM: Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, each
TO: Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement only, each

CODE: E2221
FROM: Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, each
TO: Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each

CODE: E2222
FROM: Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, each
TO: Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each

CODE: E2224
FROM: Manual wheelchair accessory, propulsion wheel excludes tire, any size, each
TO: Manual wheelchair accessory, propulsion wheel excludes tire, any size, replacement only, each

CODE: K0019
FROM: Arm pad, each
TO: Arm pad, replacement only, each

CODE: K0037
FROM: High mount flip-up footrest, each
TO: High mount flip-up footrest, replacement only, each

CODE: K0042
FROM: Standard size footplate, each
TO: Standard size footplate, replacement only, each

CODE: K0043
FROM: Footrest, lower extension tube, each
TO: Footrest, lower extension tube, replacement only, each

CODE: K0044
FROM: Footrest, upper hanger bracket, each
TO: Footrest, upper hanger bracket, replacement only, each

CODE: K0045
FROM: Footrest, complete assembly
TO: Footrest, complete assembly, replacement only, each

CODE: K0046
FROM: Elevating legrest, lower extension tube, each
TO: Elevating legrest, lower extension tube, replacement only, each

CODE: K0047
FROM: Elevating legrest, upper hanger bracket, each
TO: Elevating legrest, upper hanger bracket, replacement only, each

CODE: K0050
FROM: Ratchet assembly
TO: Ratchet assembly, replacement only

CODE: K0051
FROM: Cam release assembly, footrest or legrest, each
TO: Cam release assembly, footrest or legrest, replacement only, each

CODE: K0052
FROM: Swingaway, detachable footrests, each
TO: Swingaway, detachable footrests, replacement only, each

CODE: K0069
FROM: Rear wheel assembly, complete, with solid tire, spokes or molded, each
TO: Rear wheel assembly, complete, with solid tire, spokes or molded, replacement only, each

CODE: K0071
FROM: Front caster assembly, complete, with pneumatic tire, each
TO: Front caster assembly, complete, with pneumatic tire, replacement only, each

CODE: K0072
FROM: Front caster assembly, complete, with semipneumatic tire, each
TO: Front caster assembly, complete, with semi-pneumatic tire, replacement only, each

CODE: K0077
FROM: Front caster assembly, complete, with solid tire, each
TO: Front caster assembly, complete, with solid tire, replacement only, each

CODE: K0098
FROM: Drive belt for power wheelchair
TO: Drive belt for power wheelchair, replacement only

Revisions From MA05.044c:
11/30/2016The following HCPCS codes have been removed from Attachment A2 of this policy:

K0017 - Detachable, adjustable height armrest, base, replacement only, each
K0018 - Detachable, adjustable height armrest, upper portion, replacement only, each

Revisions From MA05.044b:
07/01/2016The Company’s coverage position for HCPCS Code E0445; Oximeter device for measuring blood oxygen levels noninvasively; has changed from Medically Necessary with criteria, to Not Covered. Therefore, the HCPCS Code E0445 was removed from Attachment A and added to Attachment B.

Revisions From MA05.044a:
01/01/2016The following HCPCS codes have been deleted from this policy: 
  • E0450 Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube)
  • E0460 Negative pressure ventilator; portable or stationary
  • E0461 Volume control ventilator, without pressure support mode, may include pressure control mode, used with non-invasive interface (e.g., mask)
  • E0463 Pressure support ventilator with volume control mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube)
  • E0464 Pressure support ventilator with volume control mode, may include pressure control mode, used with non-invasive interface (e.g., mask)
​The following HCPCS codes have been added to this policy: 
  • 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)
  • E1012 Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each
Existing durable medical equipment documentation requirements, in accordance with Medicare, are now included with examples.

Revisions From MA05.044:
01/01/2015This is a new policy.

Note: On 12/12/2014 this Notification was revised to include 1/1/2015 HCPCS coding updates.
  • Attachment A: Code A4459 has been added..
  • Codes E0856 and E0986 have revised narratives

01/01/2025
01/27/2025
N/A
MA05.044
Claim Payment Policy Bulletin
Medicare Advantage
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