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Durable Medical Equipment (DME)

Section: Durable Medical Equipment
Effective Date: January 01, 2020
Revised Date: December 26, 2019

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.

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

A4615 A4616 A4640

Anti-embolism Stockings

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

Procedure Codes

A4490 A4495 A4500 A4510

Canes
Quad Canes

  • If individual’s condition impairs ambulation.

Procedure Codes

E0100 E0105

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

E0170 E0171 E0172

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

E0163 E0165 E0168

Crutches

  • Individual’s condition impairs ambulation.

Procedure Codes

E0110 E0111 E0112 E0113 E0114 E0116

Crutch, Underarm, Articulating, Spring Assisted

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

Procedure Codes

E0117

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

E0118

Eye Pads/Patches

  • Covered for conditions such as strabismus.

Procedure Codes

A6410 A6411 A6412

Fluidic Breathing Assistor

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

Procedure Codes

E0500

Gait Trainers

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

Procedure Codes

E8000 E8001 E8002

Gloves

  • Please see Medical Policy E-2 Home Dialysis Equipment for additional information.

Procedure Codes

A4927 A4930

Haberman Feeder

  • Babies with cleft lip and/or cleft palate.

Procedure Codes

S8265

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

E0210 E0215

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

E0200  E0205

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

A8000  A8001
A8002 A8003

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.
    • Reimbursement will be made at the amount of an ordinary heating pad (refer to Heating Pads).

Procedure Codes

A9999 E1399

Injectors and Injection Aid Device

  • Individuals who are unable to use a syringe.

Procedure Codes

A4210 A4211

Intermittent Positive Pressure Breathing (IPPB) machine

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

Procedure Codes

E0500

Jaw Motion Rehabilitation System

  • Must be prescribed by a physician.

Procedure Codes

E1700 E1701 E1702

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

E0188 E0189

Non-elastic Binders for Extremities

  • For lymphedema.

Procedure Codes

A4465 S8430 S8431

Percussors (conventional)

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

Procedure Codes

E0480

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

E0481 E0484 S8185

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

E0235

Paraffin

  • If the Paraffin Bath Unit is covered.

Procedure Codes

A4265 E0235

Postural Drainage Boards

  • If individual has a chronic pulmonary condition.

Procedure Codes

E0606

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

E1399

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

E1031 E1035 E1036 E1037 E1038 E1039

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

E1399

Self-Contained Pacemaker Monitor

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

Procedure Codes

E0610 E0615

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

E0160 E0161 E0162

Standers

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

Procedure Codes

E0637 E0638 E0641 E0642

Suction Machine

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

Procedure Codes

E0600 E2000

Surgical Mask         

  • When medically necessary and used in the home.

Procedure Codes

A4928

Thermometers

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

Procedure Codes

A4931 A4932

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

E0840 E0849 E0850 E0855 E0856 E0860 E0870
E0880 E0890 E0900 E0920 E0930 E0941 E0942
E0944 E0945 E0946 E0947 E0948

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

E0705

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

E0910 E0911  E0912 E0940

Urinals

  • If individual is bed confined.

Procedure Codes

E0325 E0326

Vaporizers

  • If individual has a respiratory illness.

Procedure Codes

E0605

Walkers

  • If the individual 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

E0130 E0135 E0140 E0141 E0143 E0144 E0147
E0148 E0149

Whirlpool Bath Equipment (standard)

  • If individual is homebound and has a condition for which the whirlpool bath can be expected to provide substantial therapeutic benefit; or
  • The individual is not homebound 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

E1310

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

E0935 E0936

Non-Covered Items

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

Description Code
Adjustable high chair T5001
Auto-Tilt Chair T5001
Backrests E1399
Batteries, Replacement A4630
Bathtub Lifts, Whirlpool tub, walk-in, portable E0265, E1300, K1003
Bathtub/Shower chairs/seats E0240, E0245, E0247, E0248
Bath tub Rail, Wall Rail E0241, E0242, E0243, E0246
Carafes E1399
Carrie seats T5001
Corner chair T5001
Ear Plugs (standard or custom-made) E1399
Electric Adaptors (for car, truck, etc.) E1399
Elevators E1399
Enema/Enema Bags A4458
Enuresis (Bed Wetting) Alarm S8270
Exercise Equipment, Exercycle A9300
Feeder seats T5001
Floor sitters T5001
Grab Bars E0241, E0242, E0243, E0246
Heavy Cast Socks-6 E1399
Hot Water Bottle, ice cap or collar, heat and/or cold wrap, any type (includes ice pack) A9273
Hygienic equipment A9286
Hygienic supply A9286
Light Cast Sock-6 E1399
Linen, nonallergenic E1399
Lumbar Roll E0190
Lumex Ortho-Biotic High Back Rockers E1399
Lumex Ortho-Biotic Recliners E1399
Massage Chair/Robotic Chair E1399
Massage Devices E1399
Massage Mattress E1399
Massage Table E1399
Mileage E1399
Mobile Monomatic Sanitation System E1399
Niagara Massage Pillow E1399
Niagara Thermo-Cyclopad E1399
Positioning cushion/pillow/wedge, any shape or size E0190
Positioning Support System T5001
Posture support chair T5001
Raised Toilet Seats E0244
Reaching/Grabbing device, any type, any length, each A9281
Safety car seats E1399
Sauna Baths E1399
Silverware/Utensils E1399
Standard feeder seats T5001
Standard high chairs T5001
Telephone Arms E1399
Toilet Seats E1399
Treadmill Exerciser A9300
Tub rail attachment E0246
Tub Stool or Bench E0240, E0245, E0247, E0248
Versa Form chairs T5001
Zero gravity chair E1399

 

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

Description Code
Air Cleaners E1399
Air Conditioners E1399
Dehumidifiers E1399
Environmental control equipment E1399
Heating and Cooling Plants E1399
Humidifiers E1399
Portable Room Heaters E1399

 

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

Description Code
Braille Teaching Texts E1399
Communic-Aid E1902
Communicator E1902

 

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

Description Code
Esophageal Dilator E1399
American Bidet Toilet Seat E1399
Aquamatic K-Thermia E0217, E0236, E0249
Diathermy Machines, Low frequency ultrasonic diathermy treatment device for home use, includes all components and accessories E0761, K1004
Hydrocollator Heating Unit E0225, E0239
Intermittent Traction Unit E1399
Paraffin Bath Units – non-portable E1399
Parallel Bars E1399
Translift Chair E1399

 

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

Description Code
Disposable Sheets and Bags E1399
Incontinence Supplies and Incontinence garments and underpads A4520, A4554, T4521, T4522, T4523, T4524, T4525, T4526, T4527, T4528, T4529, T4530, T4531, T4532, T4533, T4534, T4535, T4536, T4537, T4538, T4539, T4540, T4541, T4542, T4543, T4544

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

G80.0

G80.1

G80.2

G80.4

G80.8

G80.9

G83.5

G83.81

G83.82

G83.83

G83.84

G83.89

Q05.0

Q05.1

Q05.2

Q05.3

Q05.4

Q05.5

Q05.6

Q05.7

Q05.8

Q05.9

Q07.00

Q07.01

Q07.02

Q07.03

S14.0XXA

S14.0XXD

S14.0XXS

S14.101A

S14.101D

S14.101S

S14.102A

S14.102D

S14.102S

S14.103A

S14.103D

S14.103S

S14.104A

S14.104D

S14.104S

S14.105A

S14.105D

S14.105S

S14.106A

S14.106D

S14.106S

S14.107A

S14.107D

S14.107S

S14.108A

S14.108D

S14.108S

S14.109A

S14.109D

S14.109S

S14.111A

S14.111D

S14.111S

S14.112A

S14.112D

S14.112S

S14.113A

S14.113D

S14.113S

S14.114A

S14.114D

S14.114S

S14.115A

S14.115D

S14.115S

S14.116A

S14.116D

S14.116S

S14.117A

S14.117D

S14.117S

S14.118A

S14.118D

S14.118S

S14.119A

S14.119D

S14.119S

S14.121A

S14.121D

S14.121S

S14.122A

S14.122D

S14.122S

S14.123A

S14.123D

S14.123S

S14.124A

S14.124D

S14.124S

S14.125A

S14.125D

S14.125S

S14.126A

S14.126D

S14.126S

S14.127A

S14.127D

S14.127S

S14.128A

S14.128D

S14.128S

S14.129A

S14.129D

S14.129S

S14.131A

S14.131D

S14.131S

S14.132A

S14.132D

S14.132S

S14.133A

S14.133D

S14.133S

S14.134A

S14.134D

S14.134S

S14.135A

S14.135D

S14.135S

S14.136A

S14.136D

S14.136S

S14.137A

S14.137D

S14.137S

S14.138A

S14.138D

S14.138S

S14.139A

S14.139D

S14.139S

S14.141A

S14.141D

S14.141S

S14.142A

S14.142D

S14.142S

S14.143A

S14.143D

S14.143S

S14.144A

S14.144D

S14.144S

S14.145A

S14.145D

S14.145S

S14.146A

S14.146D

S14.146S

S14.147A

S14.147D

S14.147S

S14.148A

S14.148D

S14.148S

S14.149A

S14.149D

S14.149S

S14.151A

S14.151D

S14.151S

S14.152A

S14.152D

S14.152S

S14.153A

S14.153D

S14.153S

S14.154A

S14.154D

S14.154S

S14.155A

S14.155D

S14.155S

S14.156A

S14.156D

S14.156S

S14.157A

S14.157D

S14.157S

S14.158A

S14.158D

S14.158S

S14.159A

S14.159D

S14.159S

S24.0XXA

S24.0XXD

S24.0XXS

S24.101A

S24.101D

S24.101S

S24.102A

S24.102D

S24.102S

S24.103A

S24.103D

S24.103S

S24.104A

S24.104D

S24.104S

S24.109A

S24.109D

S24.109S

S24.111A

S24.111D

S24.111S

S24.112A

S24.112D

S24.112S

S24.113A

S24.113D

S24.113S

S24.114A

S24.114D

S24.114S

S24.119A

S24.119D

S24.119S

S24.131A

S24.131D

S24.131S

S24.132A

S24.132D

S24.132S

S24.133A

S24.133D

S24.133S

S24.134A

S24.134D

S24.134S

S24.139A

S24.139D

S24.139S

S24.141A

S24.141D

S24.141S

S24.142A

S24.142D

S24.142S

S24.143A

S24.143D

S24.143S

S24.144A

S24.144D

S24.144S

S24.149A

S24.149D

S24.149S

S24.151A

S24.151D

S24.151S

S24.152A

S24.152D

S24.152S

S24.153A

S24.153D

S24.153S

S24.154A

S24.154D

S24.154S

S24.159A

S24.159D

S24.159S

S34.01XA

S34.01XD

S34.01XS

S34.02XA

S34.02XD

S34.02XS

S34.101A

S34.101D

S34.101S

S34.102A

S34.102D

S34.102S

S34.103A

S34.103D

S34.103S

S34.104A

S34.104D

S34.104S

S34.105A

S34.105D

S34.105S

S34.109A

S34.109D

S34.109S

S34.111A

S34.111D

S34.111S

S34.112A

S34.112D

S34.112S

S34.113A

S34.113D

S34.113S

S34.114A

S34.114D

S34.114S

S34.115A

S34.115D

S34.115S

S34.119A

S34.119D

S34.119S

S34.121A

S34.121D

S34.121S

S34.122A

S34.122D

S34.122S

S34.123A

S34.123D

S34.123S

S34.124A

S34.124D

S34.124S

S34.125A

S34.125D

S34.125S

S34.129A

S34.129D

S34.129S

S34.131A

S34.131D

S34.131S

S34.132A

S34.132D

S34.132S

S34.139A

S34.139D

S34.139S

S34.3XXA

S34.3XXD

S34.3XXS

 

For procedure codes A6410, A6411 and A6412

H49.00

H49.01

H49.02

H49.03

H49.10

H49.11

H49.12

H49.13

H49.20

H49.21

H49.22

H49.23

H49.30

H49.31

H49.32

H49.33

H49.40

H49.41

H49.42

H49.43

H49.881

H49.882

H49.883

H49.889

H49.9

H50.00

H50.011

H50.012

H50.021

H50.022

H50.031

H50.032

H50.041

H50.042

H50.05

H50.06

H50.07

H50.08

H50.10

H50.111

H50.112

H50.121

H50.122

H50.131

H50.132

H50.141

H50.142

H50.15

H50.16

H50.17

H50.18

H50.60

H50.611

H50.612

H50.69

H50.811

H50.812

H50.89

 

For procedure code S8265

K08.8

M26.79

Q35.1

Q35.3

Q35.5

Q35.7

Q35.9

Q36.0

Q36.1

Q36.9

Q37.0

Q37.1

Q37.2

Q37.3

Q37.4

Q37.5

Q37.8

Q37.9

 

For procedure codes A4465, S8430 and S8431

I89.0

I89.1

I89.8

I89.9

I97.2

Q82.0

 

For procedure codes E0637, E0638, E0641 and E0642

G04.1

G35

G80.0

G80.1

G80.2

G80.3

G80.4

G80.8

G80.9

G82.20

G82.21

G82.22

G83.9

R25.0

R25.1

R25.2

R25.3

R25.8

R25.9

 

For procedure codes A4931 and A4932

I12.0

I12.9

I13.0

I13.10

I13.11

I13.2

N18.1

N18.2

N18.3

N18.4

N18.5

N18.6

N18.9

N19

N99.0

 

For procedures codes E0480, E0481, E0484 and S8185

E84.0

E84.8

E84.9

E84.11

E84.19

J41.0

J41.1

J41.8

J42

J44.0

J44.1

J44.9

J45.20

J45.21

J45.22

J45.30

J45.31

J45.32

J45.40

J45.41

J45.42

J45.50

J45.51

J45.52

J45.901

J45.902

J45.909

J45.990

J45.991

J45.998

J47.0

J47.1

J47.9

Q33.4

Z48.24

Z48.280

Z94.2

Z94.3

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