Medical Policies Online - Policy #: 05.00.21f

Claim Payment Policy

Title:

Durable Medical Equipment (DME)

Policy #:

05.00.21f

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to communicate the Company's determination of codes that meet and do not meet the definition of durable medical equipment (DME).

For information on policies related to this topic, refer to the Cross References Table in this policy.

This policy does not address medical/nonreusable supplies.

Description

Company benefit contracts define durable medical equipment (DME) 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, and is appropriate for use in the home.

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. (eg, massage devices, telephone alert systems)
Equipment used for environmental control: These are items that are generally used to alter environmental temperatures or humidity. (eg, air conditioners, dehumidifiers)
Equipment inappropriate for home use: This is an item that generally requires professional supervision for proper operation.(eg, diathermy machines, medcolator)
Nonreusable supplies other than a supply that is an integral part of the DME item (ie, it is required for the DME to function): This means equipment that is not durable or is not a component of the DME. (eg, disposable sheets, irrigating kits)
Equipment that is not primarily medical in nature: Equipment that is primarily and customarily used for a non-medical purpose may or may not be considered medical in nature. This is true even though the item may have some medically related use (eg, exercise equipment, speech teaching machines).
Equipment with features of a medical nature that are not required for the individual’s condition (eg, gait trainer): 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 (eg, delivery, set-up, installation, labor, or service of rented or purchased equipment)
Modifications to vehicles, dwellings, and other structures: 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 a wheelchair.

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 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 a physician or other eligible provider.
The item is provided by a DME provider or, in limited circumstances, by another eligible provider type as allowed by the Company. For information on limited circumstances, refer to the policy addressing Preferred Provider Organization (PPO) Network Rules for Provision of Specialty Services for DME and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services.

Refer to Attachment A for a list of items that are considered DME and may be covered if other requirements are met.

Refer to Attachment B for a list of items that are benefit contract exclusions and, therefore, not covered because they are not considered DME.

Table I: Comfort and convenience items
Table II: Equipment used for environmental control
Table III: Equipment inappropriate for home use
Table IV: Nonreusable supplies other than a supply that is an integral part of the DME item
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: Services not primarily billed for by a provider
Table VIII: 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.

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
Purchased without a rental period
Always rented on a continuous basis

Authorization of DME items during the rental period is typically valid for a three-month period. Continued use beyond the three-month period may require additional authorization. Regardless of the rental period, monthly co-pays may be applicable during this rental period.

When there is a policy addressing a specific item or service, refer to the applicable policy.

MEDICARE

The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, DME is covered under the medical benefits of most Company products. Individual benefits must be verified as some contracts exclude DME. The Traditional Blue Cross Hospitalization product has no benefit for DME.

References

Company Benefit Contracts.

Centers for Medicare & Medicaid Services (CMS). Coverage Issues - Durable Medical Equipment. [CMS Web site]. Available at: http://www.cms.hhs.gov/manuals/downloads/Pub06_PART_60.pdf. Accessed August 21, 2008.

Centers for Medicare & Medicaid Services (CMS). Medicare National Coverage Determinations Manual. Chapter 1, Part 4: Coverage Determinations. [CMS Web site]. 02/23/07. Available at: http://www.cms.hhs.gov/manuals/downloads/ncd103c1_Part4.pdf. Accessed August 21, 2008.

Independence Blue Cross. Partners in Health. Proper documentation for durable medical equipment services. [Independence Blue Cross Web site]. April, 2007. Available at:http://www.ibx.com/pdfs/providers/communications/update/2007/update_apr07_ibc.pdf. Accessed August 21, 2008.

National Heritage Insurance Company. Local Coverage Determination (LCD). L15844: Cervical traction devices. [National Heritage Insurance Company Web site]. 01/01/08. http://www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/Cervical_Traction_Devices_0308.shtml. Accessed August 15, 2008.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT	N/A
ICD Procedure	N/A
ICD Diagnosis	N/A
HCPCS Level II	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.
Revenue Codes	N/A

Cross References

Associated attachments to Policy 05.00.21f: Durable Medical Equipment (DME)

	Attachment A1: Durable Medical Equipment (DME) Description: Equipment that Meets the Definition of Durable Medical Equipment (DME)
	Attachment A2: Durable Medical Equipment (DME) Description: Equipment that Meets the Definition of Durable Medical Equipment (DME)
	Attachment B: Durable Medical Equipment (DME) Description: Items that Do Not Meet the Definition of Durable Medical Equipment (DME)