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Durable Medical Equipment:

1. Items which can withstand repeated use,
2. Primarily used to serve a medical purpose,
3. Are generally not useful to a person in the absence of illness, injury, or disease, and are
4. Appropriate for use in the patient's home.

1. Benefits for Durable Medical Equipment (DME) will only be provided when:

• The equipment is prescribed by a Physician.

• The equipment does not serve as a comfort or convenience item.

2. Determination of Benefits for Durable Medical Equipment will be based on the following.

1. The equipment must meet ALL Durable Medical Equipment requirements of the Company and must meet the following criteria:

can withstand repeated use,
is primarily and customarily used to serve a medical purpose,
is generally not useful to a person in the absence of illness or injury,

is appropriate for use in the patient's home.

2. The equipment must meet ALL Medical Necessity requirements. Therefore, the equipment must be:

appropriate for the symptoms and diagnosis or treatment of the Member's condition, illness, disease or injury.
provided for the diagnosis, or the direct care and treatment or the member's condition, illness, disease or injury.
in accordance with accepted standards of medical practice.

the most appropriate supply or level of service that can safely be provided to the member.

3. Benefits for rental or purchase of Durable Medical Equipment.

• Benefits for the rental of Durable Medical Equipment 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 Durable Medical Equipment, 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 Durable Medical Equipment are considered an integral part of the rental or purchase allowable.
• 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 (added 2-27-2002).

4. Limitations in connection with Durable Medical Equipment.

• 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 Durable Medical Equipment used in Home Infusion Therapy except as provided in Article VIII, Section C.

• Benefits will not be provided for equipment where a commonly available supply or appliance can substitute to effectively serve the same purpose.

5. 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.

6. DME Exclusions

• Devices and equipment used for environmental control or enhancement (e.g., air conditioners, air filters, dehumidifiers, humidifiers, heat appliances) or
• Home modifications or improvements, including elevators and built-in lifts; or
• Vehicle modifications (e.g., hand controls, vehicle lifts, car seats) or
• Mechanical or electrical features which serve only a convenience function; or
• Computer software and hardware; or
• Items for personal comfort or conveniences such as, but not limited to, personal fitness equipment, home whirlpools or hot tubs; or
• Personal hygiene and convenience items.

None

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

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

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

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