Description

DME is defined as follows:

• Equipment must be able to withstand repeated use.
• It must be primarily and customarily used to serve a medical purpose.
• It must not be useful to a person in the absence of illness or injury.
• The equipment must be appropriate for use in the home.

All requirements of the definition must be met before an item can be considered DME.

Criteria

The following items may be considered medically necessary providing they meet the following criteria:

When the items fail to the meet the medical necessity criteria defined, they are considered not medically necessary.

Accessories

• If the individual owns or is purchasing the equipment.

Procedure Codes

Anti-embolism Stockings

• Limited to three (3) pairs in a six (6) month period.

Procedure Codes

Canes
Quad Canes

• If individual’s condition impairs ambulation.

Procedure Codes

Commode Chair with Seat Lift Mechanism

• If the individual is confined to bed or room.
• If the item is prescribed by a physician for an individual with severe arthritis of the hip or knee and for patients with muscular dystrophy or other neuromuscular diseases.

Procedure Codes

Commode Chair-on-Wheels

• If the individual is confined to bed or room confined means that the individual’s condition is such that leaving the room is medically contraindicated.
• Individuals with poor trunk where there is a safety concern with sitting unsupported and the need for a more physiologic elimination process.

Procedure Codes

Crutches

• Individual’s condition impairs ambulation.

Procedure Codes

Crutch, Underarm, Articulating, Spring Assisted

• Individuals with Spina Bifida, Cerebral Palsy, or spinal cord injury.

Procedure Codes

Crutch Substitute, Lower Leg Platform, with or without Wheels, each

• If determined to be medically necessary following below the knee injury or surgery.

Procedure Codes

Eye Pads/Patches

• Covered for conditions such as strabismus.

Procedure Codes

Fluidic Breathing Assistor

• Where there is need for intermittent positive pressure breathing (IPPB) device but oxygen is not required.

Procedure Codes

Gait Trainers

• Individuals who require moderate to maximum support for walking and who are capable of walking with this device.

Procedure Codes

Gloves

Procedure Codes

Haberman Feeder

• Babies with cleft lip and/or cleft palate.

Procedure Codes

Heating Pads
Therapeutic Fomentation Device

• When a medical review determines individual’s medical condition is one for which the application of heat in the form of a heat pad is therapeutically effective.

Procedure Codes

Heat Lamps

• When medical review determines individual’s medical condition is one for which the application of heat in the form of a heat lamp is therapeutically effective.

Procedure Codes

Helmet with Face Guard and Soft Interface Material, Prefabricated

• When ordered by a physician as medically necessary for individuals with seizure or behavior disorders who are at risk for injury to the head and face.

Procedure Codes

Hydrocollator Steam Packs

• When a medical review determines individual's medical condition is one for which the application of heat in the form of a heat pad is therapeutically effective.

Procedure Codes

Injectors and Injection Aid Device

• Individuals who are unable to use a syringe.

Procedure Codes

Intermittent Positive Pressure Breathing (IPPB) machine

• Covered if individual’s ability to breathe is severely impaired.

Procedure Codes

Jaw Motion Rehabilitation System

• Must be prescribed by a physician.

Procedure Codes

Lamb’s Wool Pads

• If individual has, or is highly susceptible to, decubitus ulcers; and individual’s physician has specified that he or she will be supervising its use in connection with his or her course of treatment.

Procedure Codes

Non-elastic Binders for Extremities

• For lymphedema.

Procedure Codes

Percussors (conventional)

• For mobilizing respiratory tract secretions inindividualswith pulmonary conditions that limit the ability to expectorate secretions, when patient or operator of the precursor has received appropriate training by a physician or therapist, and no one competent to administer manual therapy is available.

Procedure Codes

Oscillatory Devices
Flutter
Intrapulmonary Percussive Ventilation System

(Oscillatory positive expiratory pressure device, non-electric, any type, each)

• Oscillatory devices are alternatives to conventional precursor.
• Designed to provide self-administered airway clearance.
• For mobilizing secretions in patients with pulmonary conditions that limit the ability to expectorate secretions.

Procedure Codes

Paraffin Bath Units (portable)

• The individual has undergone a successful trial period of paraffin therapy when ordered by a physician; and
• The individual's condition is expected to be relieved by long term use of the modality.

Procedure Codes

Paraffin

• If the Paraffin Bath Unit is covered.

Procedure Codes

Postural Drainage Boards

• If individual has a chronic pulmonary condition.

Procedure Codes

Respirators

• Covered when a medical review determines that the apparatus specified in the claim is medically required and appropriate for home use without technical or professional supervision.

Procedure Codes

Rollabout Chairs, Transport Chairs

• When a medical review determines there is a medical need for this item and it has been prescribed by the individual's physician in lieu of a wheelchair.
• Limited to those roll about chairs having casters of at least five (5) inches in diameter and specially designed to meet the needs of ill, injured, or otherwise impaired individuals.

Customized pediatric strollers are covered for a child who is non-ambulatory when either of the following conditions applies:

• The child requires more support than is available in a standard pediatric wheelchair, or
• The child is too small to safely use a standard pediatric wheelchair.

Procedure Codes

Safety Rollers

• For obese individuals; or
• Those individuals with severe neurological disorders; or
• Those individuals with restricted use of one hand.

All claims will be referred for medical review/individual consideration.

Procedure Codes

Self-Contained Pacemaker Monitor

• When prescribed by a physician with an individual with a cardiac pacemaker.

Procedure Codes

Sitz Bath

• When the individual has an infection or injury of the perineal area and prescribed by the individual’s physician as a part of a planned regimen of treatment in the patient’s home.

Procedure Codes

Standers

• For individuals with cerebral palsy, spasticity, multiple sclerosis, and parapareses.
• For any other condition, individual consideration will be offered.

Procedure Codes

Suction Machine

• If the machine medically required and appropriate for home use without technical or professional supervision.

Procedure Codes

Surgical Mask         

• When medically necessary and used in the home.

Procedure Codes

Thermometers

• For chronic renal failure when furnished in conjunction with dialysis services.
• Must be submitted with modifier AX.

Procedure Codes

Traction Equipment

• If individual has orthopedic impairment requiring traction equipment which prevents ambulation during the period of use.
• Ambulatory traction device, all types, are considered non-covered

Procedure Codes

Transfer Board or Device, any type, each

• When determined to be necessary for the individual to function in the home and/or perform instrumental activities of daily living.

Procedure Codes

Trapeze Bars

• If individual is bed confined and the patient needs a trapeze bar to sit up due to a respiratory condition, to change body position for other medical reasons, or to get in and out of bed.

Procedure Codes

Urinals

• If individual is bed confined.

Procedure Codes

Vaporizers

• If individual has a respiratory illness.

Procedure Codes

Walkers

• If theindividual has a medical condition impairing ambulation; and
• There is a potential for ambulation; and
• There is a need for greater stability and security than provided by a cane or crutches.

Procedure Codes

Whirlpool Bath Equipment (standard)

• If individual is home bound and has a condition for which the whirlpool bath can be expected to provide substantial therapeutic benefit; or
• The individual is not home bound but has such a condition; payment will be limited to the cost of providing the services elsewhere; (e.g., an outpatient department of a participating hospital), if that alternative is less costly.

All claims will be referred for medical review.

Procedure Codes

The following is considered not medically necessary:

Continuous Passive Motion (CPM)

• Continuous Passive Motion (CPM) Devices are considered not medically necessary for all indications.

Procedure Codes

Non-Covered Items

The following items are considered convenience items, comfort items, hygienic equipment or not primarily medical in nature, and are non-covered.

The following items are considered environmental control equipment and are non-covered.

The following items are considered educational equipment; and are not primarily medical in nature and are non-covered.

The following items are considered inappropriate for home use or physician instruments or institutional equipment and are non-covered.

The following items are considered non-reusable disposable supplies and are non-covered.

Delivery, Setup and Service A9901 is non-covered as this is included in the service.

Telephone Alert Systems, E1399 are considered emergency communications systems and do not serve a diagnostic or therapeutic purpose and are therefore non-covered.

Diagnosis Codes

For procedure codes A6410, A6411, A6412

For procedure code S8265

For procedure codes A4465, S8430, S8431

For procedure codes E0637, E0638, E0641, E0642

For procedure codes A4931, A4932

For procedures codes E0480, E0481, E0484, S8185

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 adding new codes as non-covered

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.