*CAREFULLY CHECK STATE REGULATIONS AND/OR THE MEMBER CONTRACT*

NOTE: For coverage of specific durable medical equipment (DME) items please see the appropriate Medical Policy. Also, check contracts for specific DME coverage benefits.

General Coverage

Generally, DME is eligible for coverage when the equipment meets all of the following criteria:

• Serves a medical purpose; AND

• Generally not useful to a person in the absence of illness, injury, or disease; AND

• Used in the patient’s home/place of residence; AND

• Reasonable and medically necessary for the individual patient; AND

• Prescribed by a physician within the scope of his/her license; AND

• Does not serve as a comfort or convenience item; AND

• Has been approved by the US Food and Drug Administration (FDA) (where applicable) and is otherwise generally considered to be safe and effective for the purpose intended.

The following list includes, but is not limited to, examples of items that are not eligible for coverage:

• Room or central environmental conditioning devices, including but not limited to air cleaners, air conditioners, humidifiers, dehumidifiers, electrostatic machines, heaters; AND

• Bathing devices, including but not limited to whirlpool tubs and/or pumps, sauna bath; AND

• Exercise equipment, treadmill exerciser, grab bars, elevators; AND

• Leotards and other clothing type items; AND

• Supplies that are usually stocked in the home for general use, including but not limited to Band-Aids, thermometers, lubricating jelly, etc.; AND

• Transportation equipment, including but not limited to customized vehicles (cars, vans, etc.), car seats, etc.

Benefits should be provided for rental charge (but not to exceed the total cost of purchase) or, at the option of the Plan, the purchase of the DME.

Repair or Replacement of DME

Repair, adjustment, or replacement of components and accessories of DME, as well as supplies and accessories necessary for effective functioning of covered DME, are eligible for coverage when the DME:

• Meets the above general coverage criteria; AND

• Is being purchased or is already owned by patient; AND

• Requires repair or replacement that is necessary to make the DME serviceable.

Customized DME

In order to qualify as "customized,” a DME, prosthetic, or orthotic device must be specially constructed to meet an individual patient's specific needs. An invoice should be included with billing for any customized DME, prosthetic, or orthotic device for which a procedure code or HCPCS code does not exist. The prescription for customized equipment should include:

• The reason the patient requires a customized item; AND

• Specific documentation, e.g., physical therapy records or physician’s records.

The following are examples of items that do not meet the requirement to be considered customized:

• Adjustable brace with Velcro closures; AND

• Pull-on elastic brace; AND

• Lightweight, high-strength wheelchair with padding added.

Durable medical equipment (DME):

• Can withstand repeated use, i.e., could normally be rented and used by successive patients; AND

• Is primarily and customarily used to serve a medical purpose; AND

• Is generally not useful to a person in the absence of illness or injury; AND

• Is appropriate for use in the home.

Equipment that serves as a comfort or convenience item should not be considered DME. Electrical or mechanical features that enhance basic equipment usually serve a convenience function; determination of medical necessity should be made regarding the coverage of these features. Equipment used for environmental control or to enhance the environmental setting or surroundings of an individual should not be considered DME. Medical supplies should be appropriate for patient care and of proven medical value.

None.

2012 Update

Document was reviewed. No changes were noted.

2014 Update

Document was reviewed. Change noted in Policy History.

2016 Update

Document was reviewed. No changes were noted.

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

If a nationally recognized CPT or HCPCS code exists for which the narrative adequately describes a DME item, that code should be used. “Unlisted” codes have been established for services or procedures for which a code is not found in the CPT or HCPCS code manuals. When using an unlisted code, the provider must submit a detailed description of the service or equipment provided.

There is no objective basis for approval of one name-brand, specific commercial device of a particular type over another “generic" device that has an established code. DME devices billed with an unspecified code will be reimbursed at the reimbursement rate for a similar/like device with an established HCPCS or CPT code.

Benefits should be provided for rental charge (but not to exceed the total cost of purchase) or, at the option of the Plan, the purchase of the DME.

Repair or Replacement of DME

Repair, adjustment, or replacement of components and accessories of DME, as well as supplies and accessories necessary for effective functioning of covered DME, are eligible for coverage when the:

• DME meets the above general coverage criteria; AND

• DME is being purchased or is already owned by patient; AND

• Repair or replacement is necessary to make the DME serviceable.

Shipping, Delivery, Set-up, Education Regarding Use, Equipment Pick-Up

Shipping, delivery, set-up, education regarding use, and equipment pick-up generally are not separately or additionally reimbursed, as these costs are an integral part of the suppliers’ costs of doing business, and are accounted for in the calculations of fee schedules. However, in rare and unusual circumstances extraordinary delivery expenses may be considered and paid separately on an individual basis when incurred in order to meet the needs of members living in remote areas that are not served by a local dealer or when a local dealer is temporarily out of stock of required equipment.

CODING:

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

The information contained in this section is for informational purposes only. HCSC makes no representation as to the accuracy of this information. It is not to be used for claims adjudication for HCSC Plans.

The Centers for Medicare and Medicaid Services (CMS) does have a national Medicare coverage position.

A national coverage position for Medicare may have been changed since this medical policy document was written. See Medicare's National Coverage at <http://www.cms.hhs.gov>.

1. Durable Medical Equipment Introduction (Archived). Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (1995 December) Durable Medical Equipment 1.01.

2. Medical Supplies Introduction. (Archived) Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (1995 December) Durable Medical Equipment 1.02.

3. National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1), Publication 100-3. Effective date 2005. Centers for Medicare and Medicaid Services. Available at:< https://www.cms.gov> (accessed 2016 November).