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DESCRIPTIONDurable Medical Equipment (DME) is defined as items which are: (Requirements of the Company)
· The equipment is prescribed by a Physician
· The equipment does not serve as a comfort or convenience item
2. Determination of Benefits for DME will be based on the following:
· The equipment must meet ALL DME requirements of the Company
· The equipment must meet ALL Medical Necessity requirements:
3. Benefits for rental or purchase of DME:
· Benefits for the rental of DME will be based on the Company's rental Allowable Charge (but not to exceed the purchase Allowable Charge)
· At the option of the Company, Benefits will be provided for the purchase of DME, appropriate supplies, and oxygen required for therapeutic use
· Benefits based on the Allowable Charge for standard equipment will be provided toward any deluxe equipment when selected by the Member solely for the Member's comfort or convenience
· Benefits for deluxe equipment based on the Allowable Charge for deluxe equipment will only be provided when documented to be Medically Necessary
· Accessories and medical supplies necessary for the effective functioning of covered DME are considered an integral part of the rental or purchase allowance
· Benefits will be provided for the repair, adjustment or replacement of purchased Durable Medical Equipment or components only within a reasonable time period of purchase subject to the lifetime expectancy of the equipment
· The rental or purchase of appropriate DME will also include any set up or instruction charges
4. Limitations in connection with DME:
· No Benefits will be provided during rental for repair, adjustment, or replacement of components and accessories necessary for the effective functioning and maintenance of covered equipment as this is the responsibility of the Durable Medical Equipment supplier
· Benefits will not be provided for DME used in Home Infusion Therapy unless specified in the Schedule of Benefits within the Member’s benefit plan language
· Benefits will not be provided for equipment where a commonly available supply or appliance can substitute to effectively serve the same purpose
· Benefits will not be provided for construction costs to the Member’s residence to accompany the DME
· Benefits will not be provided for hot tubs, swimming pools, whirlpools, lift chairs, and air purifiers
· Benefits for the rental or purchase of all DME are subject to the limitations and exclusions within the Member’s benefit plan language
· Certain Durable Medical Equipment will require periodic re-certification during use to evaluate significant therapeutic improvement in the Subscriber's condition in order to determine the continued medical necessity for the equipment.
· Devices and equipment used for environmental control or enhancement (e.g., air conditioners, air filters, dehumidifiers, humidifiers, heat appliances)
· Home modifications or improvements, including elevators and built-in lifts
· Vehicle modifications (e.g., hand controls, vehicle lifts, car seats)
· Mechanical or electrical features which serve only a convenience function
· Computer software and hardware
· Items for personal hygiene, comfort or conveniences
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.
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