Durable medical equipment (DME) is defined as follows:

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

All requirements of the definition must be met before an item can be considered 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, e.g., safety grab bars; 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.

The following tables include items identified as DME and/or a related supply and the eligibility of those items:

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.

Coverage for DME is determined according to individual or group customer benefits.

NOTE:

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

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.

Table A:

Antiembolism Stockings (Surgical Leggings, e.g., Aero-Pulse Surgical Leggings, TEDS)(A4490-A4510) are covered if prescribed by a physician and medically necessary for treatment of illness or injury, e.g., bedridden patients.

Elastic stockings (A6530-A6549) are eligible for payment.

Heating Pads and Heat Lamps are not covered as they are considered not primarily medical in nature.

The criteria listed for Commodes, Commode Chair-on-Wheels, Commode Chair with Seat Lift Mechanism, and Hydrocollator Steam Packs is not applicable.

The Home Prothrombin Time Monitoring Device is covered, effective January 1, 1999. Benefits will be provided for any FDA approved oral anticoagulant at home monitoring device and the miscellaneous surgical supplies (code A4649), such as the strips, lancets, and other supplies, required to perform the testing.

The Osci-Lite, Paraffin, Paraffin Bath Units, Therapeutic Fomentation Device, Vaporizers and Whirlpool Bath Equipment are not covered.

Table E:

Catheters (non-urinary) and Irrigating Kits are covered.

Table F:

Delivery, set-up and service (A9901) - Combine with the charge for the equipment.

Table G:

Transport chairs (E1037, E1038, E1039) may be considered eligible if medically necessary.

PRN References

10/2001, Guidelines clarified for specific durable medical equipment
04/2002, Blue Shield discontinues trial period for non-elastic binders
04/2002, Haberman feeder allowed for cleft lip and cleft palate

MCM 2100-2105, 5101.3, 5107

MCIM 60-3, 60-4, 60-5, 60-8, 60-9, 60-11, 60-14, 60-15

DMERC LMRP L11498

CMS Transmittal AB-02-136, CR 2371

NOTE:

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

NOTE:

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

NOTE:

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

NOTE:

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

NOTE:

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

NOTE:

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

NOTE:

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