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DESCRIPTIONDurable Medical Equipment (DME) is defined as items which are: (Requirements of the Company)
1. Benefits for DME will only be provided when:
2. Determination of Benefits for DME will be based on the following:
3. Benefits for rental or purchase of DME:
4. Limitations in connection with DME:
5. DME Exclusions:
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY6/1992: Issued
9/1999: Revised based on Master Contract
4/11/2001: "Personal Comfort, Personal Hygiene, Convenience Items" policy which was issued 7/1993 has been combined with "DME" policy.
6/25/2001: Hyperlink to "DME Manual Revisions" added, which provides Claims Processing Guidelines
2/27/2002: Managed Care Requirements deleted; "The rental or purchase of appropriate DME will also include any set up or instruction charges" added
3/6/2002: Claims processing information deleted
9/11/2002: # 6 DME Exclusions revised
10/30/2013: Policy reviewed; no changes.
05/31/2016: Policy number added. Policy Guidelines updated to add medically necessary definition.
SOURCE(S)Durable Medical Equipment Manual, Page E00001 - "Personal Comfort, Personal Hygiene, Convenience Items" sources
Master Contract (12/1991) - "Personal Comfort, Personal Hygiene, Convenience Items" sources
Uniform Medical Policy Manual (11/1989) - "Personal Comfort, Personal Hygiene, Convenience Items" sources
Master Contract 1992
Master Contract, 1999
Primary Care Health Plan Contract,1999