Medicare Advantage

Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
MA05.028e

Policy

Subject to the terms and conditions of the applicable durable medical equipment (DME) provider agreement, the DME items listed in the Coding Table of this policy are not subject to a rental-to-purchase maximum and are, therefore, rented on a continuous basis, when medical necessity is established.

DME items that are not subject to a rental to purchase maximum must meet the following criteria:
  • The length of usage is expected to be greater than 15 months.
  • Equipment is either:
    • Life-sustaining, or
    • Requires specialized/frequent maintenance and service
FACE-TO-FACE REQUIREMENTS

As a condition for payment, a professional provider must have a face-to-face examination with the individual for whom the item is ordered that meets all of the following requirements:
  • ​The treating professional provider must have an in-person examination with the individual within the six (6) months prior to the date of the written order prior to delivery.
  • This encounter must document that the individual was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.
A new face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required:
  • For all claims for purchases or initial rentals
  • When there is a change in the prescription for the accessory, supply, drug, etc.
  • If periodic prescription renewal is required per medical policy
  • When an item is replaced
  • When there is a change in the supplier
  • When required by state law
In this policy the specified item(s) is (are):

CodeNarrative
E0194Air fluidized bed
E0424Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0431Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing
E0433Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and contents gauge.
E0434Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing
E0439Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
K0606Automatic external defibrillator, with integrated electrocardiogram analysis, garment type
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.

For specified DME items, documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual's clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.

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

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, du​​rable medical equipment (DME) is covered under the medical benefits of the Company’s Medicare Advantage products.

Description

Durable medical equipment (DME) is generally rented until the rental cost of the device meets the purchase price. However, the DME items listed in the Coding Table of this policy are not subject to a rental-to-purchase maximum and are, therefore, rented on a continuous basis as determined by the Company.

References

​Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 20 - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c20.pdf. Accessed November 30, 2020.

Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15 - Covered Medical and Other Health Services. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf. 
Accessed November 30, 2020.

Company Benefit Contracts.

Company Provider Contracts.

Centers for Medicare and Medicaid Services (CMS). Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Order Requirements. Available at: 
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment​. Accessed November 30, 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)
E0194Air fluidized bed
E0328Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 in above the spring, includes mattress
E0329Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 in above the spring, includes mattress
E0424Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0431Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing
E0433Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and contents gauge
E0434Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing
E0439Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, & tubing
E0445Oximeter device for measuring blood oxygen levels noninvasively
E0457Chest shell (cuirass)
E0465Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)
E0466Home ventilator, any type, used with noninvasive interface, (e.g., mask, chest shell)
E0467Home 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
E0500IPPB machine, all types, with built-in nebulization; manual or automatic valves; internal or external power source
E1390Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate
E1391Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each
E1392Portable oxygen concentrator, rental
K0455Infusion pump used for uninterrupted parenteral administration of medication, (e.g., epoprostenol or treprostinol)
K0606Automatic external defibrillator, with integrated electrocardiogram analysis, garment type
K0738Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing​



Revenue Code Number(s)
N/A



Coding and Billing Requirements


Policy History

1/18/2021
1/18/2021
MA05.028
Claim Payment Policy Bulletin
Medicare Advantage
No