Medicare Advantage

Medical Policy

Notification

Durable Medical Equipment (DME)

Notification Issued Date:

This AmeriHealth New Jersey Medicare Advantage policy will become effective 01/01/2024.

Title:

Durable Medical Equipment (DME)

Policy #:

MA05.044q

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

MPMiscCodesNarrativesPub

Coding and Billing Requirements

Cross Reference

Policy History

Version Effective Date:

4/1/2024

Version Issued Date:

5/6/2024

Version Reissued Date: