Durable Medical Equipment (DME)

POLICY NUMBER

L.1.01.400

DESCRIPTION

Durable Medical Equipment (DME) is defined as items which are: (Requirements of the Company)

• Used to serve a medical purpose

• Can withstand repeated use

• Generally not useful to a person in the absence of illness, injury or disease

• Appropriate for use in the patient’s home

POLICY

1. Benefits for 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 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:

  • 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 DME:

• Benefits for DME rental that are not classified as Rental Only will be based on the Company's rental Allowable Charge (but not to exceed the purchase Allowable Charge).

  • Rental Only Codes allowed Rental Months are as follows: Rental Months ('RR')Codes Included in the 'RR' Category

*Rental Only Code E0784 can be purchase or rental.

• 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

• RR Codes with Rental Months defined will not exceed number of RR Months defined in table.

• When RR Months have been met, ownership of the equipment passes to the Member.

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.

5. DME Exclusions:

• 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

POLICY EXCEPTIONS

State Health Plan (State and School Employees): Effective 10/01/2023, the Rental Only Codes section applies to the Advanced Health System, Inc. (AHS) Network.

POLICY GUIDELINES

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 Mental Health Disorders, 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 medical necessity, “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 HISTORY

6/1992: 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.

07/14/2023: Policy updated regarding benefits for DME rental and Rental Only Codes effective 08/01/2023. Policy Exceptions updated to state that the Rental Only Codes section does not apply to the Advanced Health System, Inc. (AHS) Network. Sources section updated.

09/25/2023: Policy section updated to add the following: "Rental Only Code E0784 can be purchase or rental." Policy Exceptions updated to state that effective 10/01/2023, the Rental Only Codes section applies to the Advanced Health System, Inc. (AHS) Network.

10/18/2023: Policy reviewed; no changes.

12/14/2023: Policy updated to add ownership transfer to Member upon RR Months exhausted.

10/16/2024: Policy reviewed; no changes.

SOURCE(S)

1. Member and Participant Benefit Plans

2. Centers for Medicare and Medicaid Services (CMS)

CODE REFERENCE

None