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.
- 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 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.
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.