Highmark Medicare Advantage Medical Policy in West Virginia

Durable medical equipment (DME) is defined as follows:

Equipment must be able to withstand repeated use, and
It must be primarily and customarily used to serve a medical purpose, and
It should not be useful to a person in the absence of illness or injury, and
The equipment should be appropriate for use in the home.

All requirements of the definition must be met before an item can be considered to be durable medical equipment.

Durability - An item is considered durable if it can withstand repeated use, i.e., the type of item which could normally be rented. Medical supplies of an expendable nature such as, incontinent pads, lambs wool pads, catheters, ace bandages, irrigating kits, sheets, and bags are not considered "durable" within the meaning of the definition.

Medical Purpose - Medical equipment is equipment which is primarily and customarily used for medical purposes and is not generally useful in the absence of illness or injury. In most instances, no development will be needed to determine whether a specific item of equipment is medical in nature. However, should it be necessary to determine whether an item constitutes medical equipment, information on the device and its use should be reviewed on an individual basis. This may include a review by the medical staff and/or specialists.

Equipment such as hospital beds, wheelchairs, iron lungs, respirators, intermittent positive pressure breathing machines, medical regulators, oxygen tents, crutches, canes, trapeze bars, walkers, inhalators, nebulizers, commodes, suction machines, and traction equipment presumptively constitute medical equipment. Hemodialysis equipment used in the home is considered DME and covered under the DME benefit.

Equipment which is primarily and customarily used for a nonmedical purpose may not be considered "medical" equipment for which payment can be made under the DME benefit. This applies even though the item has some remote medically related use. For example, in the case of a cardiac patient, an air conditioner might possibly be used to lower room temperature to reduce fluid loss in the patient and to restore an environment conducive to maintenance of the proper fluid balance. Nevertheless, because the primary and customary use of an air conditioner is a nonmedical one, the air conditioner cannot be deemed to be medical equipment for which payment can be made.

Other devices and equipment used for environmental control or to enhance the environmental setting are not considered covered DME. These include, for example, room heaters, humidifiers, dehumidifiers, and electric air cleaners. Equipment which basically serves comfort or convenience functions or is primarily for the convenience of a person caring for the patient, such as elevators, stairway elevators, and posture chairs, does not constitute medical equipment. Similarly, physical fitness equipment, e.g., an exercycle; first-aid or precautionary-type equipment, e.g., preset portable oxygen units; self-help devices; and training equipment, e.g., speech teaching machines and braille training texts, are considered nonmedical in nature.

Necessary and Reasonable — Although an item may be classified as DME, it may not be covered in every instance. Coverage in a particular case is subject to the requirement that the equipment be necessary and reasonable for treatment of an illness or injury, or to improve the functioning of a malformed body member.

Equipment is necessary when it can be expected to make a meaningful contribution to the treatment of the patient's illness or injury or to the improvement of his malformed body member. In most cases, the physician's prescription for the equipment and other available medical information will be sufficient to establish that the equipment serves this purpose.

Payment will not be made for equipment which cannot reasonably be expected to perform a therapeutic function in an individual case and only partial payment will be made when the type of equipment furnished substantially exceeds that required for the treatment of the illness or injury involved.

A request for equipment containing features of an aesthetic nature or features of a medical nature which are not required by the patient's condition or where there exists a reasonably feasible and medically appropriate alternative pattern of care which is less costly than the equipment furnished, payment will be based on the reasonable charge for the equipment or alternative treatment which meets the patient's medical needs.

Items identified as durable medical equipment (DME) and/or a related supply and the eligibility of those items is provided on the following tables.

Table A - Covered

Table B - Deny - comfort or convenience item, not primarily medical in nature.

Table C - Deny - environmental control equipment, not primarily medical in nature.

Table D - Deny - inappropriate for home use.

Table E - Deny - nonreusable supply, not rental type item.

Table F - Deny - not the customary practice to bill.

Table G - Deny - not primarily medical in nature.

Items on Tables B - G do not meet the definition of DME. Therefore, they are benefit denials and are billable to the member.

If a claim is received for an item which does not appear on the attached tables or on a related DME policy, it should be referred for medical review.

NOTE:: This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Provider News

08/2010, Phototherapy (bilirubin) light with photometer

Transmittal AB-02-136, CR 2371

NCD for Durable Medical Equipment Reference List (280.1)

Online Reference Manual 100-03, Section 20.8.2

Table A

COVERED

When the items on Table A are denied based on the medical necessity criteria defined below, they are considered not medically necessary. A provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.

Item	Variation/Additional Info
Accessories (A4615, A4616, A4630) NOT AN ALL INCLUSIVE LIST	Reimbursement may be made for replacement of essential accessories such as hoses, tubes, mouthpieces, etc., for necessary durable medical equipment, only if the patient owns or is purchasing the equipment.
Catheters (non-urinary)	Covered if appropriate for patient’s condition, ordered by a physician, and billed by an eligible provider. See “Coverage Status” information on Medicare Advantage Medical Policy Bulletin O-9 for urinary catheters.
Compression burn garments (A6501-A6513)	Covered when ordered by a physician to reduce hypertrophic scarring and joint contractures following a burn injury.
Continuous Passive Motion (CPM) Devices (E0935, E0936)	Continuous Passive Motion devices are covered as durable medical equipment for patients who have undergone reconstructive surgery of the hip or knee (e.g., total knee replacement, synovectomy, anterior cruciate ligament reconstruction, etc.). In order to qualify for such coverage, use of the device must commence within two days following surgery. In addition, such coverage is limited to that portion of the three week period following surgery during which the device is in the patient’s home. There is insufficient evidence to justify coverage of these devices for longer periods of time or for other applications.
Fluidic Breathing Assistor	Covered where there is need for IPPB device but oxygen is not required. (There are no medical indications for simultaneous home use of the assistor and an IPPB machine.)
Gait Trainers (E8000, E8001, E8002)	Covered when medically necessary for patients who require moderate to maximum support for walking and who are capable of walking with this device.
Gloves (A4927, A4930)	Covered when medically necessary and used in the home.
Grab Bars (E0241, E0242, E0243, E0246) (Safety Grab Bars)	E0241, E0243, E0246 Covered as safety items and limited to any combination of these items. Eligible for replacement every 3 years. E0242 Non-covered
Haberman Feeder (S8265)	Covered for babies with cleft lip and/or cleft palate (525.8, 749.00-749.04, 749.10-749.14, 749.20-749.25).
Helmet with face guard and soft interface material, prefabricated (A8000, A8001, A8002, A8003)	Covered 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.
Injectors and Injection Aid Devices (hypodermic jet pressure powered devices for injection of insulin and supplies for self-administered injections) (A4210, A4211)	Covered on individual consideration basis when medically appropriate or medically necessary. See Medical Policy Bulletin E-15, Diabetic Services and Supplies, for diabetic patients.
IPPB Machine (E0500) (Bennett IPPB Machine, Bird Respirator, Hands-E-Vent)	Covered if patient’s ability to breathe is severely impaired.
Irrigating Kit	Covered if appropriate for patient’s condition, ordered by a physician, and billed by an eligible provider.
Jaw Motion Rehabilitation System (E1700-E1702) (Therabite)	Covered when prescribed by a physician.
Negative Pressure Ventilators (E0460, E0472) (BiPAP S/T Ventilatory Support System, Iron Lungs)	Covered for treatment of neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary disease.
Osci-Lite	Covered under the same conditions as Heat Lamps. Limit payment to the amount which would be payable for an ordinary heat lamp.
Oscillatory Devices Flutter (S8185) Oscillatory positive expiratory pressure device, non-electric, any type, each (E0484)	Covered for mobilizing secretions in patients with pulmonary conditions that limit the ability to expectorate secretions. NOTE: Also see Medicare Advantage Medical Policy Bulletins E-68, E-72, and E-73.
Paraffin (A4265)	Covered if the Paraffin Bath Unit (E0235) is covered.
Paraffin Bath Units	STANDARD: See Table D. PORTABLE: (E0235)(Therabath) Covered when the patient has undergone a successful trial period of paraffin therapy ordered by a physician and the patient’s condition is expected to be relieved by long term use of the modality.
Percussors (E0480)	A conventional percussor is covered for mobilizing respiratory tract secretions in patients 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.
Phototherapy (bilirubin) light with photometer (E0202)	Covered for rental only. If rental is greater than one month, documentation of medical necessity is required.
Postural Drainage Boards (E0606)	Covered if patient has a chronic pulmonary condition.
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.
Rollabout Chairs (E1031, E1035) (Geriatric Chair, Glideabout Chair, Lumex Chair Table, Mobile Geriatric Chair)	Covered when a medical review determines that the patient’s condition is such that there is a medical need for this item and it has been prescribed by the patient’s physician in lieu of a wheelchair. Coverage is limited to those rollabout chairs having casters of at least five inches in diameter and specially designed to meet the needs of ill, injured, or otherwise impaired individuals. Coverage is not extended to the wide range of chairs with smaller casters as are found in general use in homes, offices, and institutions for many purposes not related to the care or treatment of ill or injured persons.
Safety Rollers	Covered for some patients who are obese, have severe neurological disorders, or restricted use of one hand, which makes it impossible to use a wheeled walker that does not have the sophisticated breaking system found on safety rollers. To assure that a less expensive standard wheeled walker would not satisfy the patient’s medical needs, refer all claims for medical review/individual consideration.
Self-Contained Pacemaker Monitor (E0610, E0615) (Audible/Visible Signal Pacemaker Monitor, Digital Electronic Pacemaker Monitors, Pac Trac)	Covered when prescribed by a physician for a patient with a cardiac pacemaker.
Shipping Charges	Covered on home dialysis supplies only.
Sitz Bath (E0160-E0162)	Covered when a medical review determines patient has an infection or injury of the perineal area and the item has been prescribed by the patient’s physician as a part of his planned regimen of treatment in the patient’s home.
Standers (E0637, E0638, E0641, E0642)	Covered for patients with cerebral palsy (333.71, 343.0-343.9), spasticity (781.0), multiple sclerosis (340), and parapareses (344.1, 344.9). NOTE: For other conditions, individual consideration will be offered.
Surgical Mask (face mask) (A4928)	Covered when medically necessary and used in the home.
Traction Equipment (E0900, E0920, E0930, E0941, E0942, E0944-E0948)	Covered if patient has orthopedic impairment requiring traction equipment which prevents ambulation during the period of use. (Consider covering devices usable during ambulation, e.g., cervical traction collar, under the brace provision.) NOTE: E0830 (Ambulatory traction device, all types, each), is not covered.
Transfer board or device, any type, each (E0705)	Covered when determined to be necessary for the patient to function in the home and/or perform instrumental activities of daily living.
Tub/Shower Chair	Covered. Limit – 1 bath tub stool or bench (E0245), chair (E0240), or tub transfer bench (E1399) every three years.
Tub Stool/Bench (E0245)	Covered. Limit – 1 bath tub stool or bench (E0245), chair (E0240), or tub transfer bench (E1399) every three years.
Tub Transfer Bench	Covered. Limit - 1 bath tub stool or bench (E0245), chair (E0240), or tub transfer bench (E1399) every three years.
Urinals (autoclavable hospital type) (E0325, E0326)	Covered if patient is bed confined.
Vaporizers (E0605)	Covered if the patient has a respiratory illness.
Whirlpool Bath Equipment (standard) (E1310)	Covered if patient is homebound and has a condition for which the whirlpool bath can be expected to provide substantial therapeutic benefit justifying its cost. Where patient is not homebound but has such a condition, payment is restricted to the cost of providing the services elsewhere, e.g., an outpatient department of a participating hospital, if that alternative is less costly. Refer all claims for medical review.

NOTE:: Code E1399, durable medical equipment, miscellaneous, should be applied to those procedures listed without a designated procedure code.

Table B

Deny

Comfort or convenience;
not primarily medical in nature