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Date Printed: August 23, 2017: 05:49 AM

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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.

09-E0000-01

Original Effective Date: 12/15/02

Reviewed: 02/26/15

Revised: 03/15/15

Subject: Durable Medical Equipment (DME)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
Other References Updates    

DESCRIPTION:

Please refer to the individual's Certificate of Coverage for availability of benefit and any pre-authorization necessary for the rental/purchase of Durable Medical Equipment (DME). Certain items of covered DME are off-the-shelf items with standard design. Others, however, must be custom-built for the patient to their physical specifications and/or a physician’s prescription. Requests for such items are always subject to medical review.

Durable Medical Equipment (DME) is any equipment that provides therapeutic benefits to a patient because of certain medical conditions and/or illnesses. DME includes, but is not limited to, wheelchairs (manual or electric), hospital beds, traction equipment, canes, crutches, walkers, kidney machines, ventilators, oxygen, monitors, pressure mattresses, lifts, nebulizers, bili blankets and bili lights.

The Centers for Medicare and Medicaid Services (CMS) defines DME as any equipment that:

Medical supplies that may be needed for patients to care for themselves at home (e.g., ostomy supplies) are a separate issue from supplies needed to maintain durable medical equipment. These types of medical supplies are not address in this guideline.

Although convenience items may be associated with secondary medical uses, the principal or primary use of a convenience item is usually not medical, e.g. an elevator or an over-bed table.

Additional or duplicate items of DME used for the same purpose, but not at the same time (e.g. for home/work/school) are considered convenience, e.g., additional and/or "backup" glucometers, wheelchairs, etc.

Durable Medical Equipment when provided by a Durable Medical Equipment Provider and when prescribed by a Physician, is limited to the most cost effective Durable Medical Equipment that meets the member’s needs as determined by BCBSF.

"Deluxe" electrical or mechanical features, which enhance basic equipment usually serve a convenience function and will therefore be reviewed for medical necessity.

POSITION STATEMENT:

Durable Medical Equipment meets the definition of medical necessity when ALL of the following criteria are met:

DME purchase and rental fees include equipment delivery services and set-up, and education and training for patient and family. These services are not eligible for separate reimbursement.

DME rental fees will cover the cost of maintenance, repairs, replacements, adjustments, supplies, and accessories.

Reimbursement will begin on the day the device is delivered to the member.

For some equipment, coverage may include a trial rental period to ensure efficacy of treatment before purchase determination.

Maintenance, Repairs, and Replacement of Purchased DME

Repairs or maintenance to equipment that is purchased may be considered eligible for coverage on an individual consideration basis when necessary to make the equipment usable.

Maintenance, Repairs, and Replacement of Rented DME

Replacement of the rental equipment may occur when the rented item is irreparably damaged, or if replacement is required during repair and/or maintenance of a specific item. Monthly rental fees allow for the replacement costs, and are not eligible for separate reimbursement.

Coverage for Optional DME Features

Optional DME equipment or features will be reviewed on an individual consideration basis for medical necessity.

Optional DME equipment or accessories are generally considered contract exclusions and are not eligible for coverage unless covered per specific contract benefit:

Equipment delivery services and set-up, education and training for patient and family, and nursing visits, are not eligible for separate reimbursement regardless of agreement to rent or purchase.

BILLING/CODING INFORMATION:

The appropriate HCPCS code should be used describing the durable medical equipment (E0100 – E8002; and K0001 – K0899).

REIMBURSEMENT INFORMATION:

Refer to sections entitled POSITION STATEMENT and OTHER.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products: The following National Coverage Determination (NCD) was reviewed on the last guideline reviewed date: Durable Medical Equipment 280.1 located at cms.gov.

DEFINITIONS:

Comfort or Convenience: a convenience item is any object/device that increases physical comfort without serving a medically necessary purpose, such as a bedside table.

Condition: a disease, illness, ailment, injury, bodily malfunction, or pregnancy.

Durable Medical Equipment (DME): equipment furnished by a supplier or a Home Health Agency that (1) can withstand repeated use; (2) is primarily and customarily used to serve a medical purpose; (3) not for comfort or convenience; (4) generally is not useful to an individual in the absence of a Condition; and (5) is appropriate for use in the home.

Durable Medical Equipment Provider: a person or entity that is properly licensed, if applicable, under Florida law (or a similar applicable law of another state) to provide home medical equipment, oxygen therapy services, or dialysis supplies in the patient’s home under a Physician’s prescription.

Environmental Control: environmental control equipment is any device or appliance that alters or maintains the conditions in the existing surroundings, such as an air conditioning unit.

Exercise equipment: exercise equipment is any device or object that serves as a means to allow for energetic physical action or exertion in order to train, strengthen or condition all or part of the human body.

Furniture: furniture items are movable articles or accessories which serve as a place upon which to rest (people or things) or in which things are placed or stored, such as a chair or a dresser.

Home Health Agency: a properly licensed agency or organization which provides health services in the home pursuant to Chapter 400 of the Florida Statutes, or similar applicable law of another state.

RELATED GUIDELINES:

Refer to other individual MCGs for additional information on specific DME items.

OTHER:

The Attached Table represents some of the more commonly encountered items, which may be submitted as DME (the "Effective Date" of this guideline, reflects the effective date of this table). The list is not all-inclusive as new devices are constantly being invented and marketed. When an item is encountered which is not on the list, this item must be medically reviewed for a determination.

REFERENCES:

  1. American Association of Homecare website. Accessed 07/19/07.
  2. Blue Cross Blue Shield Association Medical Policy – Durable Medical Equipment Introduction 1.01 (12/01/95).
  3. Blue Cross Blue Shield Association Medical Policy – Medical Supplies Introduction 1.02 (12/01/95).
  4. Centers for Medicare and Medicare Services (CMS) National Coverage Determination for Durable Medical Equipment, Publication 100-3, Section 280.1 (07/05/05). Accessed 01/05/15.
  5. Code of Federal Regulations. Accessed 10/02/09.
  6. Medicare Coverage Issues Manual (CIM Durable Medical Equipment 60-3 through 60-24).
  7. Medicare Region C DMERC Local Coverage Determinations (LCD). Accessed 10/01/09.
  8. St. Anthony’s Durable Medical Equipment Billing Guide.
  9. St. Anthony’s HCPCS Level II Code Book (current edition).

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 02/26/15.

GUIDELINE UPDATE INFORMATION:

12/05/02

Medical Coverage Guideline Reformatted and DME Table developed.

01/01/03

Annual HCPCS coding update (added E0761).

12/15/04

Scheduled review; added items to DME Table with cross-references to existing MCGs.

01/15/05

Annual HCPCS coding update (gait trainer added to DME table).

07/01/05

3rd Quarter HCPCS coding update (added enuresis alarm to DME table); added gait belts to DME table; revised information regarding gait trainer.

10/15/05

Revision; added portable, battery-powered, hand held nebulizer to DME table.

01/01/06

Annual HCPCS coding update; (commode seat lift mechanisms, standing frames, and transfer boards and devices added to DME Table).

11/15/06

Scheduled review; update DME Table; add “post-vitrectomy face-down devices” to DME table; added cross-references to other individual DME MCGs.

07/15/07

DME Table updated to remove cross-reference links to archived MCGs.

09/15/07

Reviewed; reformatted guideline; updated references.

11/15/09

Scheduled review; position statements unchanged; DME table and references updated.

06/01/12

Revision: revised DME Table reference to breast pumps.

09/06/13

Revision: revised DME Table reference to electric breast pumps; Program Exception section updated; references updated.

03/15/15

Revisions and reformatting, including DME Table.

Date Printed: August 23, 2017: 05:49 AM