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Date Printed: December 18, 2017: 03:22 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

DME Table (attachment to DME MCG 09-E0000-01)

Last Updated: 11/15/15

       

Ambulatory Assist
Devices

Diabetic Equipment/Supplies

Heat and Cold
Applications

Positive Airway
Pressure Devices

       

Bath and Toilet Aids

Electrical Neuromuscular/ Bone Growth Stimulators

Light Sources/
Equipment

Wheelchairs
(Mobility Equipment)

       

Beds/Bedding Accessories/Cushions/Pads

Environmental Control Devices

Monitoring
Equipment

Wound Care
Equipment

       

Communication Devices

Exercise and Massage Equipment

Oxygen and Respiratory Equipment/ Humidifiers/Dehumidifiers

Miscellaneous Equipment/Devices

       

Compression Pumps/Garments/Devices

Furniture
(Chairs, Tables)

Patient Lifts/Transfer Equipment/Elevators

Previous
Version

       

Ambulatory Assist Devices

 

 

 

 

Item

Description

Guidelines

Coverage

Medicare Coverage

Canes and Accessories

A wooden stick or metal rod used for support in walking.

Medically necessary for patients with impaired ambulation or vision when medically indicated.

Approve

 

Crutches and Accessories

A support typically fitting under the armpit for use by the disabled in walking.

Medically necessary for patients with impaired ambulation when medically indicated.

Approve

 

Gait Trainer
(E8000– E8002)

A device made of lightweight metal tubing, sometimes with wheels, for patients who need more support for walking than that given by a cane or a crutch.

Medically necessary when prescribed by a physician to provide support to the patient similar to a walker but because the gait trainer has items such as arm prompts, chest prompts, and stabilizing belts, the gait trainer provides support, such that if a patient were to lose their balance or lose their strength the gait trainer will support the patient to avoid falling.

Approve

For more information, see Medicare DMERC LCD for Walkers (L11450)
(www.cms.hhs.gov)

Roll-A-Bout or (Rollabout),Crutch Substitute, Knee crutch/hands-free walker (e.g., Roll-A-Bout walker, Rolleraid™, iWALKFree™, Easy Crutch, Turning Leg Caddy®) (E0118)

An assistive 4-wheeled device, similar to a walker but with a handle and a support pad on which the patient places the knee of the injured leg, while ambulating with the non-injured leg, or hands-free crutch.

Medically necessary in lieu of a standard walker for patients following below knee injuries when their condition is such that they are unable to bear weight on the affected leg and:

• Unable to use crutches due to an inability to support upper body, OR

• Lack of an upper extremity to sustain weight with crutches, standard walkers or other standard ambulatory assist devices, OR

• The patient has tried and failed use of a standard ambulatory assist device.

Approve

 

Stander /Prone Stander (E0638)

One position (e.g. upright, supine or prone stander), any size including pediatric, with or without wheels

Passive (static) stander: A passive stander remains in one place, sometimes has casters but cannot be self-propelled; most prone/supine

A device used to accommodate both adults and children in the standing position when they are unable to obtain optimum positioning due to a disease process.

Medically necessary when prescribed by a physician as part of a therapeutic program to prevent contractures (hip, knees, ankles), reduce spasticity, and prevent pressure ulcers through a change of position. Standing may also alleviate pain or discomfort from other prolonged positions, assist healthy skeletal development. Replacement standers are considered medically necessary when the stander’s adjustments no longer can accommodate the patient’s growth.

Approve

 

Standing Frame System, Multi-Position or Mobile (E0637, E0641, E0642)

Examples: 3-way stander, dynamic stander, any size including pediatric.

Active stander: An active stander creates reciprocal movement of the arms legs while standing. Most of these are sit- to- stand type devices.

Mobile (dynamic) stander: User can self-propel a mobile stander if they have upper body strength to push a manual wheelchair. Some standers are also available with powered mobility; (also known as multi-positioning standers)

Deluxe item.

Deny

 

Walker and Accessories
(Standard Walker)

A device made of lightweight metal tubing, sometimes with wheels, for patients who need more support for walking than that given by a cane or a crutch.

Medically necessary for patients with impaired ambulation who needs greater stability and security than can be provided by a cane or crutches when medically indicated.

Approve

 

Walker and Accessories
(Heavy Duty Walker)

A device made of heaver metal tubing for support of extra body weight, sometimes with wheels, for patients who need more support for walking than that given by a cane or a crutch.

Medically necessary for patients with impaired ambulation who needs greater stability and security than can be provided by a cane or crutches and who weigh more than 300 pounds when medically indicated.

Approve

 

White Cane

Safety and guidance item for the sightless.

Considered a self-help item.

Deny

 
 

Bath and Toilet Aids

Item

Description

Guidelines

Coverage

Medicare Coverage

Bathroom Equipment

Accessory equipment utilized in the bathroom that increases comfort of use. Includes items such as bathtub lifts, bathtub seats, tub rails, tub chairs, etc.

Convenience items.

Deny

 

Bed Pan

As titled.

Medically necessary for bedridden patients.

Approve

 

Commode, Bedside and Accessories

A portable toilet.

Medically necessary for patients confined to a bed, a room or one floor of their home without a bathroom.

Approve

 

Commode Chair with Integrated Seat Lift

Commode chair with integrated seat lift mechanism, electric or non-electric, any type.

Convenience/deluxe item.

Deny

For more information, see Medicare LCD website for Commodes (L4991)
(www.cms.hhs.gov)

Commode Seat Lift Mechanism

Seat lift mechanism placed over or on top of toilet, any type.

Convenience/deluxe item.

Deny

For more information, see Medicare LCD website for Commodes (L4991)
(www.cms.hhs.gov)

Sauna Bath

A small room used for a dry heat bath.

Does not meet DME criteria.

Deny

 

Sitz Bath

A device shaped like a chair in which one bathes in a sitting position, immersing only the hips and buttocks.

Medically necessary for treatment of infection or injury of the perineal area when medically indicated.

Approve

 

Toilet Seat (Includes Raised)

As titled.

Does not meet criteria in DME MCG

See also MCG for Non-Covered Services, 09-A0000-00.

Deny

 

Urinals
(Male and Female) (Autoclavable)

A receptacle used for urination for a patient in bed.

Medically necessary for bedridden patients.

Approve

 

Whirlpool
(i.e. Jacuzzis, Hot Tubs, Swimming Pools, Whirlpool Bath Equipment, Pumps, Portable Pumps)

A therapeutic bath in which all or part of the body is exposed to forceful whirling currents of hot water.

Not suitable for home use. Whirlpool therapy is a professional service.

Deny

For more information, see Medicare NCD Durable Medical Equipment Reference List (280.1)
(www.cms.hhs.gov)

 

Beds/Bedding Accessories/Cushions/Pads

Item

Description

Guidelines

Coverage

Medicare Coverage

Air Fluidized Bed, Powered Air Flotation Bed, Bead Bed (e.g. Clinitron), Other Powered Pressure Relieving Beds

As titled

See MCG Hospital Beds and Accessories, 09-E0000-12

See Medical Coverage Guideline

 

Alternating Pressure Pads

A system that utilizes a pump to alternately inflate and deflate cells in a mattress to relieve excessive pressure points on a patient’s body.

Medically necessary for patient’s that is either fully or partially immobile when medically indicated.

Approve

 

Bedboard

A rigid board put under the mattress of a bed for firm support of the patient.

Does not meet DME criteria.

Deny

 

Bed Cradle

A frame placed over the body of a bed patient for protecting injured parts from contact with bedclothes.

Medically necessary for patients with severe extremity wounds when medically indicated.

Approve

 

Bed, Hospital
(Total Electric)

A hospital bed with electric head, foot, and height adjustment controls

See MCG Hospital Beds and Accessories, 09-E0000-12

See Medical Coverage Guideline

 

Bed, Hospital
(Semi-Electric)

Hospital bed with electric head and foot adjustment

See MCG Hospital Beds and Accessories, 09-E0000-12

See Medical Coverage Guideline

 

Bed, Hospital
(Manual)

As titled

See MCG Hospital Beds and Accessories, 09-E0000-12

See Medical Coverage Guideline

 

Bedside Rails

Rails attached to a hospital bed to provide protection to patients at risk for falling out of bed.

Medically necessary for patients with risk of injury when they have received a hospital bed.

Approve

 

Cushion, Car Seat
(Obus Form)

A cushion used on car seats to relieve back pain and correct posture.

Does not meet DME criteria.

Deny

 

Cushion, Gel

Flotation cushion that provides supportive seating surface on a wheelchair for pressure reduction/ management.

Medically necessary for use with a wheelchair. Other uses are for convenience.

Approve

 

Footboard

A device that attaches to the bed to provide foot support and prevent foot drop and rotation.

Medically necessary for the prevention of foot drop of a bedridden patient.

Approve

 

Lambs’ Wool Pad

A thin mat or cushion-like pad made of soft material (e.g. lambs’ wool).

Convenience item

Deny

For more information, see Medicare NCD for Durable Medical Equipment (280.1)
(www.cms.hhs.gov)

Springbase Bed; Stryker Frame Bed

Institutional equipment

See MCG Hospital Beds and Accessories, 09-E0000-12

See Medical Coverage Guideline

 

Trapeze Equipment And Fracture Frame

A structure attached to the bed to support patient positioning.

Medically necessary for bed-confined patients who need a trapeze bar to sit up due to a respiratory condition, to change body position or for patients with limited ambulation with other medical reason(s) to get in and out of bed.

Approve

 
 

Communication Devices

Item

Description

Guidelines

Coverage

Medicare Coverage

Anti-Stuttering Devices

A device used to reduce stuttering and increase speech fluency.

See MCG Speech Therapy, 01-92506-01.

See Medical Coverage Guideline

 

Communication Board, Non-Electronic Augmentative or Alternative Communication Device

Any non-electronic device used by individuals with speech impairments, to convey a message to another (e.g. chalk board, non-electronic display, notepad, etc.)

Does not meet DME criteria.

Deny

 

Speech Generating Devices

Electronic devices used for communication by individuals that do not have the ability to speak. Includes devices such as but not limited to Communic Aid, Communicator, Electric or computer devices and software programs, touch talker, Voicaid.

See MCG Speech Generating Devices, 09-E0000-51.

See Medical Coverage Guideline

 
 

Compression Pumps/Garments/Devices

Item

Description

Guidelines

Coverage

Medicare Coverage

Gradient Compression Garment used instead of a pneumatic compression pump or device such as the Reid Sleeve (A6530-A6541, A6545, A6549, S8420-S8429)

Article of custom-fitted clothing that applies constant gradient pressure to the part of the body it covers.

See MCG Lymphedema Pumps and Devices, 09-E0000-31 and End Diastolic Pneumatic Compression Boot, 09-E0000-48.

See Medical Coverage Guideline

 

Gradient Compression Stockings

Typically recommended for individuals who are prone to blood clots, lower limb lymphedema, and blood pooling in the legs and feet.

See MCG for Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers 09-E0000-31 and MCG for Treatments for Varicose Veins/Venous Insufficiency, 02-33000-31

See Medical Coverage Guidelines

For more information, see Medicare LCD 11449 for Surgical Dressings (www.cms.hhs.gov)

Lymphedema Pump
(Pneumatic Compression Device) (Segmental And Non-Segmental)

A device that uses pneumatic pressure sleeves to reduce swelling (edema) caused by lymph accumulations in extremities.

See MCG Lymphedema Pumps and Devices, 09-E0000-31.

See Medical Coverage Guideline

 
 

Diabetic Equipment/Supplies

Item

Description

Guidelines

Coverage

Medicare Coverage

Blood Glucose Monitor, Continuous

Automatically measures glucose values throughout the day to produce data that shows trends in glucose measurements.

See MCG Continuous Monitoring of Glucose in the Interstitial Fluid, 01-99000-03.

See Medical Coverage Guideline

 

Blood Glucose Monitor, Standard (Glucometer)

An instrument used to measure the level of glucose (sugar) in the blood.

See MCG Blood Glucose Monitors and Supplies, 09-E0000-14.

Medically necessary for patients with diabetes.

Not the same as MCG Continuous Glucose Monitoring of The Interstitial Fluid, 01-99000-03.

See Medical Coverage Guideline

 

Blood Glucose Monitor With Special Features

 

See MCG Blood Glucose Monitors and Supplies, 09-E0000-14.

Medically necessary for patients having a severe visual impairment that prevents the use of a standard blood glucose monitor.

See Medical Coverage Guideline

 

Insulin Pen (e.g. Novopen)
(Insulin Injecting Device)

An insulin delivery system.

Medically necessary for diabetic patients unable to perform standard insulin syringe injections.

Approve

 

Insulin Pump

A device for injecting a measured amount of insulin during a specific interval of time.

See MCG External Insulin Infusion Pumps and Supplies, 09-E0000-11.

See Medical Coverage Guideline

 

Laser Lancets

Laser skin piercing devices used in place of spring powered devices for lancets

See MCG Blood Glucose Monitors and Supplies, 09-E0000-14.

See Medical Coverage Guideline

 

Medijector (A4210)

A needle-free injectable drug (e.g. insulin) delivery system.

Medically necessary for diabetic patients unable to perform standard insulin syringe injections.

Approve

 

Injection port (e.g., i-Port Advance®)

An injection port applied to the skin in order to take multiple injections without having to puncture the skin for each dose.

Comfort or convenience item

Deny

 
 

Electrical Neuromuscular/Bone Growth Stimulators

Item

Description

Guidelines

Coverage

Medicare Coverage

Accutron (Microcurrent Electrotherapy)

TENS unit that utilizes microampere electrical current.

See MCG Transcutaneous Electric Nerve Stimulation (TENS), 02-61000-04.

See Medical Coverage Guideline

 

Alpha-Stim

TENS unit that utilizes microampere electrical current.

See MCG Transcutaneous Electric Nerve Stimulation (TENS), 02-61000-04.

See Medical Coverage Guideline

 

Bone Growth Stimulators:

See various types below.

This is not the same as an implanted spinal stimulator, which is not a piece of DME. The non-invasive type of bone growth stimulator is a piece of durable medical equipment.

 

 

Non-Invasive Electrical
(e.g. Spinal Stim, Ebi)

This non-invasive method uses external power and externally applied power coils that produce pulsed electromagnetic fields (PEMFs) that generate a current through a site where bone growth is desired.

See MCG Non-Invasive Electrical Bone Growth Stimulators (EBGS), 09-E0000-22.

See Medical Coverage Guideline

 

Invasive
(e.g. Spinal Fusion Device)

The invasive method uses a current generator that is surgically implanted in an intramuscular or subcutaneous space connected to an electrode that is implanted within the bone fragments where fusion is desired.

See MCG Non-Invasive Electrical Bone Growth Stimulators (EBGS), 09-E0000-22.

Not considered DME

 

Central Nervous System Neurostimulator

An implanted device and electrodes with a programmable transmitter that may be worn externally or may also be fully implanted.

See MCG Spinal Cord Stimulation, 02-61000-05.

Not considered DME

 

Electrical Bladder Stimulator
(Innova®)

A monitor, sensor, and/or trainer for the treatment of urinary incontinence.

See MCG Pelvic Floor Stimulation as a Treatment of Urinary Incontinence, 01-97000-06.

Investigational

 

Functional Neuromuscular Stimulator, Surface Application

A device that transmits an electrical impulse to the skin over selected muscle groups by way of electrodes.

See MCG Functional Neuromuscular Stimulation, 01-95805-15.

Investigational

 

Interferential Unit

TENS unit that utilizes microampere electrical current.

See MCG Transcutaneous Electric Nerve Stimulation (TENS), 02-61000-04.

See Medical Coverage Guideline

 

Neuromuscular Stimulator, Electrical

A device that transmits an electrical impulse to the skin over selected muscle groups by way of electrodes.

See MCG Functional Neuromuscular Stimulation, 01-95805-15.

See Medical Coverage Guideline

 

Pelvic Floor Stimulator
(Empi® Innova®)

A monitor, sensor, and/or trainer for the treatment of urinary incontinence.

See MCG Pelvic Floor Stimulation as a Treatment of Urinary Incontinence, 01-97000-06.

Investigational

 

Percutaneous Electrical Nerve Stimulation (PENS)

A device that transmits an electrical impulse though surgically implanted electrodes connected by leads to a receiver unit that is placed beneath the skin.

See MCG Percutaneous Electrical Nerve stimulation (PENS), 02-61000-03.

Not considered DME

 

Sacral Nerve Stimulator

A surgically implanted pulse generator and wire leads controlled by an external control magnet over the pulse generator.

See MCG Sacral Nerve Stimulation for Urinary Incontinence, 02-61000-23.

Not considered DME

 

Threshold Therapeutic Electrical Stimulator

A device that delivers electrical stimulation during sleep, 8-12 hours, to increase muscle strength.

See MCG Threshold Therapeutic Electrical Stimulation (TES), 09-E0000-34.

See Medical Coverage Guideline

 

Transcutaneous Electrical Nerve Stimulator
(TENS)

An electronic device that applies electrical stimulation to the surface of the skin used to treat pain.

See MCG Transcutaneous Electrical Nerve Stimulation (TENS), 02-61000-04.

See Medical Coverage Guideline

 

Ultrasound Accelerated Fracture Healing Device

A non-invasive bone growth stimulator device that uses a low intensity pulsed ultrasound signal that is applied to the skin overlying the fracture site to aid in its clinical repair.

See MCG Ultrasound Osteogenesis Stimulators, Non-Invasive, 09-E00000-32.

See Medical Coverage Guideline

 
 

Environmental Control Devices

Item

Description

Guidelines

Coverage

Medicare Coverage

Air Cleaners
(Air Purifiers)

An indoor system for removal of air pollutants.

Environmental control equipment.

Deny

 

Air Conditioners

A system for indoor ventilation and temperature control.

Environmental control equipment.

Deny

 

Dehumidifier
(Room Or Central)

An indoor device that removes moisture from the air.

Environmental control equipment.

Deny

 

Fans

Device for circulating air.

Convenience item.

Deny

 

Humidifier
(Room Or Central)

An indoor device for supplying or maintaining a degree of moisture in the air.

Environmental control equipment.

Deny

 

Vaporizer

A system that administers cool or heated mist into the air.

Environmental control equipment.

Deny

 

Water Softener (Other Than For Hemodialysis) Or Purifiers

As titled

Environmental control equipment, convenience item

Deny

 
 

Exercise and Massage Equipment

Item

Description

Guidelines

Coverage

Medicare Coverage

Anti-Gravity Devices

An exercise device that counteracts the pull of gravity.

Exercise equipment.

Deny

 

Continuous Passive Motion (CPM) Machine

An electrical device designed to maintain range of motion in joints. It is usually applied to an extremity and held in place with Velcro straps to move the joint at variable range of motion and speed, without patient assistance, on a continuous 24 hour basis.

See MCG Continuous Passive Motion Devices, 09-E0000-15

See Medical Coverage Guideline

 

Continuous Passive Motion Kit

Medical supplies utilized for the functioning of a CPM machine (e.g. sheep’s skin pad, elastic).

See MCG Continuous Passive Motion Devices, 09-E0000-15.

See Medical Coverage Guideline

 

Exercise Equipment

Devices for development or training of the body.

Exercise equipment. Includes treadmills, weights, home gyms, ski-tracks, stationary bikes, Ergometers, etc.

Deny

 

Massage Device

As titled.

Does not meet DME criteria.

Deny

 

Parallel Bars

As titled

Institutional equipment not for home use.

Deny

 

Tilt Table

As titled

Does not meet DME criteria.

Deny

 

Treadmill

As titled

Exercise equipment

Deny

 
 

Furniture (Chairs, Tables)

Item

Description

Guidelines

Coverage

Medicare Coverage

Bedside Table

A portable table, usually on wheels, that remains nearby a bed.

Convenience item.

Deny

 

Chair, Auto-Tilt
(Chair And Mechanism)

Mechanized chair that tilts to aid the patient into the standing position.

See MCG Seat Lift Mechanisms 09-E0000-52.

See Medical Coverage Guideline

 

Chair, Geriatric

A high-back chair with lap tray that may or may not be mounted on wheels, which allows a patient to tilt to a reclining position.

Furniture item.

Deny

 

Commercially-available furniture (i.e., CraftMatic, SleepNumber, Tempurpedic beds, bed wedges, reclining chairs, etc.)

Furniture that is available from retailers, internet sites without a prescription

Does not meet DME criteria

Deny

 

Over Bed Table

A table on wheels that adjusts height and fits over the bed.

Convenience item.

Deny

 
 

Heat and Cold Applications

Item

Description

Guidelines

Coverage

Medicare Coverage

Cold Therapy Devices
(e.g. Cryo/Cuff, Polar Care, Cold Pad)

Water circulating cold pad with pump with or without compression.

See MCG Cooling and Heating Devices, 09-E0000-53

See Medical Coverage Guideline

 

Heating Pad (Standard)

As titled.

Does not meet DME criteria.

Deny

For more information, see Medicare NCD for Durable Medical Equipment (280.1)

Heating Pad (Steam Pad)

As titled.

Does not meet DME criteria.

Deny

For more information, see Medicare NCD for Durable Medical Equipment (280.1)
(www.cms.hhs.gov)

Hydrocollator unit with pads; Hydrocollator, portable

A device that steams heat packs.

Does not meet DME criteria.

Deny

For more information, see Medicare NCD for Durable Medical Equipment (280.1)
(www.cms.hhs.gov)

Water circulating heat pad with pump

 

See MCG Cooling and Heating Devices, 09-E0000-53

See Medical Coverage Guideline

 

Seat Lift mechanism added to patient owned chair

Mechanized seat in a chair, which tilts to aid the patient into the standing position.

See MCG Seat Lift Mechanisms 09-E0000-52.

See Medical Coverage Guideline

 
 

Light Sources/Equipment

Item

Description

Guidelines

Coverage

Medicare Coverage

Heat Lamp, table model or with stand

As titled.

Does not meet DME criteria.

Deny

For more information, see Medicare NCD for Durable Medical Equipment (280.1)
(www.cms.hhs.gov)

Phototherapy Lights:

Home lighting units used for the application of light for therapeutic purposes.

See below.

See below

 

Bili-Light
Lamp, Light Panel, Or Special Light Blanket

A light source designed to provide continuous ultraviolet light to a neonate.

Medically necessary for the treatment of hyperbilirubinemia in the newborn.

Approve

 

Sun Or Light Box Or Lighting Equipment (Cabinet or table models)

A lamp designed to provide white light equaling the intensity of a bright summer day – 2500 lux or higher.

Does not meet DME criteria.

Deny

 

Sunglasses, Puva

Glasses that absorb ultraviolet light.

Included in PUVA treatment.

Deny

 
 

Monitoring Equipment

Item

Description

Guidelines

Coverage

Medicare Coverage

Apnea Monitor (Home)

A device for monitoring breathing and heart rate.

See MCG Home Apnea Monitor, 09-E0000-50.

See Medical Coverage Guideline

 

Automated Ambulatory Blood Pressure Monitor

A portable device that records blood pressure while the patient is involved in daily activities.

See MCG Ambulatory Blood Pressure Monitoring (ABPM), 01-93875-16.

See Medical Coverage Guideline

 

Enuresis Or Incontinence Treatment System (Bedwetting) Alarm/Sensor

Bedwetting alarm using auditory buzzer and/or vibration device.

Does not meet DME criteria.

Deny

 

Polar Heart

A watch worn to calculate heart rate (pulse) and respiratory rate.

Convenience item.

Deny

 

Pulse Monitor

A device used to calculate heart rate.

Does not meet DME criteria.

Deny

 

Uterine Monitor, Home

A device used to aid in identifying/ recording contractions in patients who are at risk for pre-term labor.

See MCG Home Uterine Activity Monitoring (HUAM), 03-59000-11.

Investigational

 
 

Patient Lifts/Transfer Equipment/Elevators

Item

Description

Guidelines

Coverage

Medicare Coverage

Bathtub Lift

Used to assist in transferring patient in and out of bathtub.

Convenience item.

Deny

 

Elevator

A platform or small room capable of being raised or lowered to carry passengers or freight.

Convenience item.

Deny

 

Gait Belt

Used by caregivers in assisting with patient transfers.

Convenience item.

Deny

 

Patient Transfer System (Lifts, Hydraulic)
(e.g. Hoyer Lift)

A system that a caregiver can use to transfer the patient from bed to chair and back.

Medically necessary for indicated conditions (e.g. paralysis, severe obesity, pathological bone fracture risk, etc.).

Approve

For more information, see Medicare LCD for Patient Lifts (L11562)
(www.cms.hhs.gov)

Patient Transfer System (e.g. Sure Lift, Ski-Lift Type Equipment)

Multi-positional patient support system, with integrated lift, patient accessible controls, or caregiver operated

Patient lift, fixed system

A system that transfers the individual around the home in a seat that travels on a track attached to the ceiling.

A multi-positional transfer system allows positioning and adjustment so a bedbound patient can be transferred in the supine position.

Patient lift fixed system is a mechanism attached to permanent ceiling tracks or a wall mounting system and which is used in a room other than the bathroom.

Convenience item

Deny

 

Stairway Elevators/ Stair Lift (e.g. Stairglide) Platform Lift, Escalators

A chair or platform deck attached to the wall of a stairwell that serves to transport the seated individual up and down the stairs.

Convenience item.

Deny

 

Transfer Board Or Device

As titled.

Convenience item

Deny

 

Van Lift

As titled.

Convenience item.

Deny

 

Car Lift (Trunk Lifts)

Device that lifts scooters and wheelchairs into a car trunk or onto the roof of the car.

Convenience item.

Deny

 

Wheelchair Lift or Ramp

A lift or sloping passage that connects different levels.

Convenience item.

Deny

 
 

Positive Airway Pressure Devices

Item

Description

Guidelines

Coverage

Medicare Coverage

BIPAP

A bi-level Continuous Positive Airway Pressure (CPAP) device that delivers positive airway pressure at different levels to treat sleep apnea.

See MCG Continuous Positive Airway Pressure (CPAP); Bilevel Positive Airway Pressure (Bi PAP);, 09-E0000-21.

See Medical Coverage Guideline

 

Continuous Positive Airway Pressure (CPAP) Equipment

Used in the treatment of sleep apnea, CPAP is delivered by a flow generator through a nasal mask to supply a pressure level sufficient enough to keep the upper airway open.

See MCG Continuous Positive Airway Pressure (CPAP); Bilevel Positive Airway Pressure (Bi PAP); D, 09-E0000-21.

See Medical Coverage Guideline

 
 

Oxygen and Respiratory Equipment/Humidifiers/Dehumidifiers

Item

Description

Guidelines

Coverage

Medicare Coverage

Chest Wall Oscillating Device, High Frequency Chest Compression Device
(Therapy Vest)

A high frequency chest compression vest designed for self-administration of chest physiotherapy.

See MCG Oscillatory Devices (The Vest Airway Clearance System, Percussionaire, Flutter Device), 09-E0000-28.

See Medical Coverage Guideline

 

Flutter Inhalation Therapy Device

A device that facilitates clearing of mucus from the respiratory tract through vibration on the thoracic region.

See Oscillatory Devices (The Vest Airway Clearance System, Percussionaire, Flutter Device), MCG 09-E0000-28.

See Medical Coverage Guideline

 

Humidifier (Oxygen)

A device that attaches to an oxygen delivery system to put moisture into the oxygen.

Medically necessary as part of an oxygen delivery system.

Approve

 

Intermittent Positive Pressure Breathing Machine (IPPB)
(e.g. Bird, Bennett, Bendix)

A respiratory treatment involving periodic inflation of the lungs.

Medically necessary for the treatment of pulmonary diseases or severely impaired breathing.

Approve

 

Intrapulmonary Percussive Ventilator (IPV)

A form of chest physical therapy that delivers mini-bursts (more than 200 per minute) of respiratory gasses to the lungs via a mouthpiece. Its intended purpose is to mobilize endobronchial secretions.

See Oscillatory Devices (The Vest Airway Clearance System, Percussionaire, Flutter Device), MCG 09-E0000-28.

See Medical Coverage Guideline

 

Nebulizer
(Portable, Battery-Powered, Hand Held)

Used to administer respiratory treatments.

Convenience item.

Deny

 

Oxygen and Respiratory Equipment

Oxygen is a gas administered by inhalation-utilizing devices (respiratory equipment) that provide controlled oxygen concentrations and flow rates to the patient to maintain adequate tissue and cell oxygenation.

See MCG Oxygen, 09-E0400.

See Medical Coverage Guideline

 

Peak Flow Meter
(Spirometer)

A device that measures exhalation to determine whether medications are effective, or an asthma attack is severe enough to warrant emergency care.

Medically necessary for asthmatic patients. This is not the same as MCG Home Spirometry, 09-E0000-36.

Approve

 

Percussion Device

Used to provide effective chest therapy by simulating the clapping action of manual percussion.

See MCG Oscillatory Devices (The Vest Airway Clearance System, Percussionaire, Flutter Device), MCG 09-E0000-28.

See Medical Coverage Guideline

 

Pulse Oximeter

A non-invasive tool that continuously measures the arterial hemoglobin oxygen saturation.

See MCG Oxygen, 09-E0400, and Home Pulse Oximetry 09-E0000-49.

See Medical Coverage Guideline

 

Spirometer

A device for the measurement of pulmonary function.

See MCG Home Spirometry, 09-E0000-36.

See Medical Coverage Guideline

 

Suction Machine/Pump

A device utilized to assist in the removal of excessive secretions.

Medically necessary for respiratory conditions, tracheostomy, laryngectomy, etc., when medically indicated.

Approve

 

Therapy Vest
(American Biosystems Chest Percussor)

A high frequency chest compression vest designed for self-administration of chest physiotherapy.

See MCG Oscillatory Devices (The Vest Airway Clearance System, Percussionaire, Flutter Device), 09-E0000-28.

See Medical Coverage Guideline

 
 

Wheelchairs (Mobility Equipment)

Item

Description

Guidelines

Coverage

Medicare Coverage

Roll-About Chair

Chairs having casters of at least 5 inches in diameter and specifically designed to meet the needs of the impaired individual.

See MCG Wheelchairs and Wheelchair Accessories, 09-E0000-35.

See Medical Coverage Guideline

 

Scooter
(Power Operated And Electric)

A 2- or 3-wheeled automotive vehicle with a seat that provides transportation.

See MCG Wheelchairs and Wheelchair Accessories, 09-E0000-35.

See Medical Coverage Guideline

 

Wheelchair, Manual

(Standard, Special Size And Custom) (e.g. Amputee, Fully-Reclining, Heavy Duty, Semi-Reclining)

An occupant-propelled chair mounted on wheels for the use of disabled individuals.

See MCG

Wheelchairs and Wheelchair Accessories, 09-E0000-35.

See Medical Coverage Guideline

 

Wheelchair, Power Operated

An electrically powered chair mounted on wheels for the use of disabled individuals.

Wheelchairs and Wheelchair Accessories, 09-E0000-35.

See Medical Coverage Guideline

 

Wheelchair Accessories

These items are additions to the basic wheelchair that may include such things as trays, brake extensions, cushions, upholstery, casters, tires, arm rests, etc.

See MCG

Wheelchairs and Wheelchair Accessories, 09-E0000-35.

See Medical Coverage Guideline

 
 

Wound Care Equipment

Item

Description

Guidelines

Coverage

Medicare Coverage

Diapulse / Diathermy Machine
(Standard Or Pulse-Wave)

An electronic device that provides pulsed high peak electromagnetic energy to an open wound or painful area to relieve pain and reduce edema.

See MCG Physical Therapy (Physical Medicine), 01-97000-01.

Investigational

 

Infrared and Low Level Laser Energy Devices

A device used in the treatment of wounds.

MCG Infrared and Lower Level Laser Energy, 09-E0000-44.

See Medical Coverage Guideline

 

Non-Contact Radiant Heat Bandage

A wound and burn occlusive heated dressing for the treatment of acute and chronic wounds.

See MCG Non-Contact Radiant Heat Bandage for the Treatment of Wounds, 09-E0000-42.

See Medical Coverage Guideline

 
 

Miscellaneous Equipment/Devices

Item

Description

Guidelines

Coverage

Medicare Coverage

Ambulatory Blood Pressure Monitoring (ABPM)

Fully automated monitor that records several blood pressure measurements over a 24-hour to 72 hour period at preprogrammed intervals.

See Medical Coverage Guideline Ambulatory Blood Pressure Monitoring 01-93875-16

See Medical Coverage Guideline

For more information, see Medicare

NCD 20.19 at cms.gov and

LCD 93784 located at fcso.com.

Blood Pressure Cuff (Sphygmomanometer), automated or manual, with or without stethoscope

Used for blood pressure.

Does not meet DME criteria.

Deny

 

Bowel Irrigation/ Evacuation System

A tubing system used to flush the body of solid waste.

Medically necessary when medically indicated.

Approve

 

Bra, Mastectomy

A garment used to hold breast prosthesis in place post-mastectomy.

Medically necessary for patients post-mastectomy. See MCG Prosthetics, 09-L0000-05.

Approve

 

Breast Pump, manual or electric

A device for extracting milk from the breasts of a lactating woman.

Per federal mandate, allow purchase of one (1) pump per delivery following childbirth.

Approve

 

Breast pump, hospital or institutional grade

Hospital grade pumps have stronger, more powerful motors that provide a higher level of suction and increased pumping efficiency in order to create and sustain an adequate milk supply. These pumps are larger and heavier, which in turn makes them less easy to transport than personal pump counterparts.

Hospital-grade breast pumps are not covered except when Medically Necessary during an inpatient stay.

Deny

 

Car Hand Controls

Device that is custom-built into a standard car that enables individuals to operate a car without the use of their legs/feet.

Convenience item.

Deny

 

Car Seats (For Special Needs Children)

As titled

Does not meet DME criteria.

Deny

 

Cranial Remodeling Helmets And Bands (e.g. Doc Band, Star Band)

For treating plagiocephaly.

See MCG Cranial Orthosis, 09-L0000-02.

See Medical Coverage Guideline

 

Driving Aids
(e.g. Car Hand Controls, Foot Pedal Adapters, Foot Pedal Elevators, Etc.)

Assistive devices custom-built into a standard car that enable a disabled individual to operate the car independently.

Convenience item.

Deny

 

Face-Down Devices; Post-Vitrectomy (e.g. Pillows, Chairs)

Devices that facilitate in the healing process following vitrectomy.

Face-down pillow is considered medically necessary following vitrectomy; chair is considered a convenience item.

Allow pillow; deny chair

 

Helmet

A head covering that provides protection against head injury.

Does not meet DME criteria.

NOTE: Not the same as Dynamic Orthotic Cranioplasty. See MCG Cranial Orthosis as a Treatment for Plagiocephaly, 09-L0000-02.

Deny

 

Infusion Pump
(E.G.,CADD)

A device for injecting a measured amount of fluid during a specific interval of time.

See MCG External Infusion Pumps (non-insulin), 09-E0000-10.

See Medical Coverage Guideline

 

Intravenous Pole (I.V. Pole)

A pole with a wide base from which a bag/bottle of fluid is hung for intravenous or enteral infusions via gravity.

Medically necessary for patients who require infusions and enteral feeding or when determined to be otherwise medically indicated.

Approve

 

Mechanical Mobilization Device

Dynamic and static-progressive splints used for treating contractures.

See MCG Mechanical Stretching Devices, 09-E0000-47.

See Medical Coverage Guideline

 

Paraffin Bath

A heated wax bath for arthritis or other joint discomfort.

Does not meet DME criteria.

Deny

 

Personal Care Items (Tooth Brush, Eating Utensils) or

Personal Adaptive Devices (Tongs, Lifters, Special Door Handles, Grabbers)

As titled

Does not meet DME criteria.

Deny

 

Pulsed Fecal Irrigation Device

A device used for treating fecal impactions.

Medically necessary when medically indicated.

Approve

 

Restorator

A device that restores hair growth through stimulation of the scalp.

Does not meet DME criteria.

Deny

 

Rinoflow

A nasal wash device.

Convenience item.

Deny

 

Spinal Unloading Devices

Traction-like device for low back pain.

See MCG Spinal Unloading Devices and Pneumatic Traction Devices, 09-E0000-40.

See Medical Coverage Guideline

 

Stethoscope

For listening to heart rate and rhythms

Does not meet DME criteria.

Deny

 

Traction Equipment And Weights

Equipment that creates a situation of tension for a skeletal structure.

NOTE: Equipment prevents ambulation during period of use.

Medically necessary for orthopedic impairment requiring traction equipment when medically indicated.

Approve

 

Transtympanic Micropressure Application Device (e.g. Meniett Device)

A device used for the treatment of Meniere’s disease.

See MCG Transtympanic Micropressure Applications, 09-E0000-46.

See Medical Coverage Guideline

 

Vacuum Assisted Erectile Device (e.g. Erect Aid)

A non-invasive hand held device that uses the vacuum/constriction concept that causes an erection. It is a round vacuum chamber or cylinder that inverses pressure.

Medically necessary for patients with erectile dysfunction.

Approve

For more information see Medicare LCD L34675

Wigs

As titled

Subject to individual member contract benefits

Refer to member contract language

 

Date Printed: December 18, 2017: 03:22 PM