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Repair and Replacement of Durable Medical Equipment (DME) and Prosthetic Devices
05.00.44t

Policy

DURABLE MEDICAL EQUIPMENT

Repair or replacement of durable medical equipment (DME), or of a medically necessary accessory that is needed for the essential functioning of the DME in relation to the individual's condition, is covered and eligible for reimbursement consideration by the Company as follows:

REPAIR
The repair of a DME item or accessory is covered and eligible for reimbursement consideration when all of the following are met:
  • The repair of DME is covered under the member's benefit contract.
    • Benefits for the repair of DME are provided in accordance with the member benefit contract and vary by product and group. For specific coverage criteria regarding limits and existing contractual exclusions, individual member benefits must be verified.
  • The DME item itself is covered.
  • The DME or accessory is provided by a DME supplier.
  • The cost to repair, rather than replace, the item is justified based on the useful lifetime of the item.
  • The continued use of the DME remains medically necessary.
Labor associated with the repair of DME is eligible for separate reimbursement consideration and is reported using the applicable Health Common Procedure Coding System (HCPCS) Level II code.

REPLACEMENT
The replacement of a previously approved DME item or accessory is covered and eligible for reimbursement consideration when all of the following criteria are met:
  • The replacement of DME is covered under the member's benefit contract.
    • Benefits for the replacement of DME are provided in accordance with the member benefit contract and vary by product and group. For specific coverage criteria regarding limits and existing contractual exclusions, individual member benefits must be verified.
  • The DME item itself is covered.
  • The replacement DME item or accessory is provided by a DME supplier.
  • The continued use of the DME remains medically necessary for the individual.
  • The DME replacement is not an additional item (e.g., for use when traveling or for an additional residence).
  • The replacement is equivalent to a previously approved DME item.
  • The replacement accessory is for a DME item previously owned/purchased by or for the individual and either one of the following applies:
    • There is a change in the individual's condition that requires a replacement (e.g., weight loss or gain, growth)
    • The DME does not function properly because it has reached or exceeded its life expectancy as determined by the manufacturer.

The Company may determine the reasonable useful lifetime of a specific item based on the manufacturer's recommendation or the Food and Drug Administration (FDA)--approved labeling. In the absence of the manufacturer's recommendations or FDA labeling, the Company may determine the reasonable useful lifetime of a specific item, but in no case can it be less than 5 years. Replacement due to wear is not covered during the reasonable useful lifetime of the equipment; however, the Company will cover repair up to the cost of replacement for medically necessary equipment owned by the individual.


Requests for technological advancements or newly released upgrades to equipment, when the original equipment still functions properly and/or there are no significant changes in the individual's condition, are considered not medically necessary and are not covered.

REPAIR AND REPLACEMENT

If a rental item breaks, it is the individual's responsibility to work with the Company to replace or repair the item.​

If a purchased item breaks and is under warranty, it is the individual's responsibility to work with the manufacturer to replace or repair the item.

If a purchased item breaks and is not under warranty, the Company will provide benefits for the repair or replacement of the item as long as the above criteria are met.

The Company does not cover repair or replacement of DME due to abuse or loss of the item. In such instances, therefore, repair and replacement of DME are not eligible for reimbursement with the following exception: DME may be replaced in cases of loss for individuals enrolled in Medicare Advantage products.

PROSTHETIC DEVICES

 

Please note that State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

The repair or replacement of a prosthetic device, supplies, or one or more of its components (parts) is covered and eligible for reimbursement consideration by the Company when the prosthetic device itself is covered under the individual's medical benefits and all of the following requirements for a repair or replacement are met.

Coverage of the repair or replacement of prosthetic devices and associated supplies and components (parts) may vary by product and/or group contract. Therefore, individual member benefits must be verified.


REPAIR

The repair of a prosthetic device or one or more of its components (parts) is covered and eligible for reimbursement consideration by the Company when all of the following requirements are met:

  • The prosthetic device does not function properly.
  • The device is not under a manufacturer's warranty.
  • The repair of the device is covered under the individual's medical benefits.

Please note: As some benefit contracts limit or exclude the repair of certain covered prosthetic devices, individual member benefits must be verified.

  • The cost to repair the device or its components (parts) is less than the cost to replace it and is justified based on the useful life of the prosthetic device as determined by the manufacturer.
  • The continued use of the device remains medically necessary and appropriate for the individual's condition.

The labor associated with the repair of a prosthetic device is covered and eligible for separate reimbursement consideration and is reported using the applicable Healthcare Common Procedure Coding System (HCPCS) Level II code (refer to the attached Coding Table below).


REPLACEMENT

The replacement of a previously approved  prosthetic device or one or more of its components (parts) or supplies is covered and eligible for reimbursement consideration by the Company when all of the following requirements are met:

  • The replacement device is covered under the individual's medical benefits. Please note: As some benefit contracts limit or exclude the replacement of certain covered prosthetic devices, individual member benefits must be verified.
  • The replacement device is provided by an eligible ancillary provider.
  • The continued use of the device remains medically necessary for the individual and appropriate for the individual's condition.
  • The replacement is not an additional device (e.g., for use when traveling or for an additional residence).
  • The replacement is equivalent to a previously approved prosthetic device/component.
  • The device itself is not under a manufacturer's warranty. However, the replacement of a supply to a covered prosthetic device is covered.
  • The replacement device is for an individual who has either one of the following:
    • A change in condition that impacts the fit or function of the device and, therefore, requires its replacement (e.g., growth)
    • A device that does not function properly and has reached or exceeded its useful lifetime duration as determined by the manufacturer
​​The Company may determine the reasonable useful lifetime of a specific prosthetic device based on the manufacturer's recommendation or the Food and Drug Administration (FDA)--approved labeling.

In the absence of manufacturer's recommendations or FDA labeling, the Company may determine the reasonable useful lifetime of a specific prosthetic device, but is generally not less than five years. Replacement due to misuse, abuse, or failure to adequately maintain or care for the item is excluded from coverage.

Requests for a different type of a prosthetic device or one or more of its components (parts) due to a change in medical and/or functional status, such that the prosthesis can no longer meet the individual's needs for control, durability (maintenance), function (speed, work capability), and usability are considered new requests, not requests for replacement. These requests are evaluated against the medical necessity criteria for the new type of prosthesis requested.


NONCOVERED REPAIR OR REPLACEMENT

The repair or replacement of a prosthetic device or one or more of its components (parts) is considered noncovered and not eligible for reimbursement consideration by the Company in each of the following circumstances:

  • The device itself is a benefit exclusion.
  • The request is for a visual prosthetic device (i.e., medically necessary glasses or contact lenses covered under the individual's medical benefit), which is not a benefit for most products of the Company. However, this repair or replacement statement of noncoverage does not apply to an ocular prosthesis, which is an artificial eye that replaces a missing eye due to congenital anomaly, disease, surgical removal (enucleation), or trauma.
  • The request is for a technologically advanced or newly released upgrade to an original device that still functions properly and/or there is no significant change in the individual's condition.
  • The device or one or more of its components (parts) is under a manufacturer's warranty. In this case, it is the individual's responsibility to arrange the repair or replacement of a prosthetic device with the manufacturer while it is under warranty.
  • The request is solely being made to allow or enhance an individual's leisure, recreational activity, appearance, or athletic performance.
  • The request is due to the abuse or loss of the device.
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 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

The repair and/or replacement of DME and associated accessories should be reported using the specific code describing the repair or replacement item. Items without a specific replacement code should be reported using the standard code for the item being replaced.

This policy addresses repair and replacement of DME in general. When there is a policy addressing the repair or replacement of a specialized or specific item, the information in the specific policy supersedes this general policy.

The repair or replacement of prosthetic devices and associated components (parts), accessories, and associated supplies is reported using the specific repair or replacement Healthcare Common Procedure Coding System (HCPCS) procedure code corresponding to the item, when available. The labor related to the repair of external prosthetic devices is reported using the applicable HCPCS procedure code(s).

This policy addresses the repair or replacement of a prosthetic devices and associated components (parts) and supplies in general. When there is a policy addressing a specific type of a prosthetic device or associated component (part) or supply, the information in the specific policy supersedes this general policy.​

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, the repair or replacement of prosthetic devices and associated components (parts), accessories, and supplies is covered under the medical benefits of most of the Company's products. Coverage and reimbursement for the repair or replacement of prosthetic devices vary by product and/or group contract. Therefore, individual member benefits must be verified.​​

Description

Durable medical equipment (DME) is 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, wheelchairs, commodes, crutches, and hospital beds.

Repair is the restoration of a DME item or one of its components to correct problems due to wear, damage, or defect.

Replacement is the removal and substitution of a DME item or one of its components that is necessary for proper functioning.

A prosthesis is a device that replaces all or part of an absent body organ, including contiguous tissue, or the function of a permanently inoperative or malfunctioning body organ. An external prosthetic device is a prosthesis that is worn on or external to the body such as, but not limited to, an artificial limb.


A supply or component (part) of a prosthetic device is one that is necessary for the essential functioning of the prosthetic device in relation to the individual's condition.

The repair of a prosthetic device or component is the restoration of the device or one or more of its components (parts) to correct problems due to wear or damage.

The replacement of a prosthetic device is the removal and substitution of the device or one or more of its components (parts) or supplies that are necessary for its proper functioning.​

References

Centers for Medicare & Medicaid Services (CMS). Carriers Manual. Part 3 - Claims Process. Chapter II - Coverage and Limitations. §2100.1: Definition of Durable Medical Equipment. [CMS Web site]. 09/27/01. Available at:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1725B3.pdf. Accessed October 21, 2020.

Centers for Medicare & Medicaid Services (CMS). Carriers Manual. Part 3 - Claims Process. Chapter II - Coverage and Limitations. §2100.4: Repairs, Maintenance, Replacement, and Delivery. [CMS Web site]. 09/08/05. Available at:https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R1725B3.pdf. Accessed October 21, 2020.

Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15 - Covered Medical and Other Health Services. §110.2: Repairs, Maintenance, Replacement, and Delivery. [CMS Web site.] 07/12/19. Available at:
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf. Accessed October 21, 2020.

Centers for Medicare and Medicaid Services (CMS). Transmittal #30. Change Request (CR) #3693: Policy for Repair and Replacement of Durable Medical Equipment (DME). [CMS Web site]. 02/18/05. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R30BP.pdf. Accessed October 21, 2020.

Centers for Medicare and Medicaid Services (CMS). Transmittal #3713. Change Request (CR) #9966: Extension of Payment Change for Group 3 Complex Rehabilitative Power Wheelchairs Accessories and Seat and Back Cushions under Section 16005 of the 21st Century Cures Act. [CMS Web site]. 02/03/17. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3713CP.pdf. Accessed October 21, 2020.

Company Benefit Contracts.

Provider Manual for Participating Professional Providers (Provider Manual).

Centers for Medicare & Medicaid Services (CMS). Medicare Claims Processing Manual. Chapter 20 – Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). 10.1.3 - Prosthetics and Orthotics (Leg, Arm, Back, and Neck Braces, Trusses, and Artificial Legs, Arms, and Eyes.) [CMS Web site]. 07/31/20. Available at: http://www.cms.hhs.gov/manuals/downloads/clm104c20.pdf. Accessed October 21, 2020.

New Jersey (NJ) Legislature. P.L. 2007, Chapter 345. Senate No. 502. Requires health benefits coverage by health insurers and SHBP for orthotic and prosthetic appliances and provides reimbursement. [NJ State Legislature Web site]. 01/13/08. Available at:
http://www.njleg.state.nj.us/2006/Bills/AL07/345_.PDF. Accessed October 21, 2020.

New Jersey Permanent Statutes. Title 17. Ch 48. §6b: Benefits for reconstructive breast surgery. [New Jersey Legislature Web site]. Original: 1983 (Amended: 1997). Available at: 

https://lis.njleg.state.nj.us/nxt/gateway.dll?f=templates&fn=default.htm&vid=Publish:10.1048/Enu Accessed October 21, 2020.

Noridian Health Care Solutions, LLC. Local Coverage Article. Facial Prostheses - Policy Article (A52463). Revised Effective 01/01/2020. Original effective: 10/01/2015.  https://med.noridianmedicare.com/documents/2230703/7218263/Facial+Prostheses+LCD+and+PA  Accessed October 19, 2017.

Social Security Administration (SSA), The. Compilation of the Social Security Laws. Replacement of prosthetic devices and parts. SEC. 1834. [42 U.S.C. 1395m] §1834 - (h) (1) (g). [SSA Web site]. 06/28/06. Available at: http://www.ssa.gov/OP_Home/ssact/title18/1834.htm#fnr147. Accessed October 21, 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)
See Attachment A.
Revenue Code Number(s)
N/A

Modifiers

WHEN THERE IS NO SPECIFIC HCPCS CODE FOR THE REPAIR OR REPLACEMENT OF A DME OR PROSTHETIC DEVICE, THE FOLLOWING MODIFIER IS APPENDED TO THE HCPCS CODE FOR THE DEVICE ITSELF:


RA Replacement of a DME, Orthotic or Prosthetic item
RB Replacement of a part of a DME, Orthotic or Prosthetic item furnished as part of a repair​


Coding and Billing Requirements

Policy History

Revisions From 05.00.44t:
10/01/2025This policy has been indentified and updated for the HCPCS code update effective 10/01/2025​​.

​HCPCS code A4288 has been added to this policy.


Revisions From 05.00.44s:
04/01/2025This policy has been indentified and updated for the HCPCS code update effective 04/01/2025​​.

​HCPCS code L6031 has been added to this policy.


HCPCS code A4453 has been removed from the policy.


Revisions From 05.00.44r:
10/01/2024This policy has been indentified and updated for the HCPCS code update effective 10/01/2024​.

​HCPCS code L8721 has been added to this policy.​


Revisions From 05.00.44q:
01/02/2024This policy has been indentified and updated for the HCPCS code update effective 01/02/2024​.

​HCPCS code A4457 has been added to this policy


HCPCS code K1013 has been removed from this policy.


Revisions From 05.00.44p:
04/01/2023This policy has been indentified and updated for the HCPCS code update effective 04/01/2023.

​The following procedure codes have been added to Attachment A of this policy:

A4341 and A4342


Revisions From 05.00.44o:
10/01/2021This policy has been updated for the HCPCS code update, effective 10/01/2021.

The following HCPCS narrative has been revised in Attachment A of this policy:

K1013​: Enema tube, with or without adapter, any type, replacement only, each

​

The following procedure code has been added to Attachment A of this policy:

A4453: Rectal catheter for use with the manual pump-operated enema system, replacement only​

Revisions From 05.00.44n:
04/01/2021This policy has been updated for the HCPCS code update, effective 04/01/2021.

The following procedure code has been added to Attachment A of this policy:

K1013​: Enema tube, any type, replacement only, each​


 Revisions From 05.00.44m:
02/08/2021

This version of the policy will become effective 02/08/2021.

 

This policy has been updated to communicate the Company's continuing position on repair and replacement of DME. In this version applicable codes and information from the archived Repair and Replacement of Prosthetic Devices were included.​

 

​The following HCPCS codes have been added: A7020, E2225, E2226, K0015, K0070,L5704, L5705, L5706, L5707,L7902, L8696

 

The following HCPCS codes have been deleted: A4638, A4639, A4890, A7031, A7032, A7033, A7045, A7046, A7502, E0249, K1010, K1011, K1012

 

The following HCPCS codes have been transferred into this policy from retired 05.00.45L: A4363, A5113, A5114, L5700, L5701, L5702, L5703, L5971, L6883, L6884, L6885, L6915, L7367, L7368, L7510, L7520, L8048, L8049, L8505, L8511, L8512, L8513, L8514, L8615, L8616, L8617, L8618, L8619, L8621, L8622, L8623,L8624, L8625,L8627, L8628, L8629, L8681, L8684, L8689, L8691, L8693,L8694, L8695

​ 

Revisions From 05.00.44l:
10/01/2020This policy has been updated for the HCPCS code update, effective 10/01/2020.

The following HCPCS codes has been added to the policy:

K1010: Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each

K1011: Activation device for intraurethral drainage device with valve, replacement only, each

K1012: Charger and base station for intraurethral activation device, replacement only​


Revisions From 05.00.44k:
10/01/2018This policy has been updated for the HCPCS code update, effective 10/01/2018.

The following HCPCS code has been termed from the policy:

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


10/1/2025
10/10/2025
05.00.44
Claim Payment Policy Bulletin
Commercial
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No