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| Section: |
Durable Medical Equipment |
| Number: |
E-38 |
| Topic: |
Continuous Rental of Life Sustaining Durable Medical Equipment (DME) |
| Effective Date: |
August 1, 2005 |
| Issued Date: |
August 1, 2005 |
| Date Last Reviewed: |
07/2005 |
General Policy Guidelines
Indications and Limitations of Coverage
While some items of durable medical equipment (DME) are for purchase only, numerous DME items can be rented or purchased. However, when an item of DME is rented, the total rental payments may not exceed the allowable purchase price of the item, unless the item has been identified as life sustaining DME. Life sustaining DME items can be continuously rented as long as the need exists for the equipment.
A list of items identified as life sustaining DME is in the Table Attachment below.
Coverage for DME is determined according to individual or group customer benefits. |
Procedure Codes
| E0194 | E0431 | E0434 | E0439 | E0445 | E0450 |
| E0460 | E0461 | E0463 | E0464 | E0471 | E0472 |
| E1390 | E1391 | K0671 | | | |
Traditional Guidelines
FEP Guidelines
PPO Guidelines
Managed Care POS Guidelines
Publications
References
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Table Attachment
Life Sustaining DME Items
| E0194 |
Air fluidized bed
- NOTE:
- For additional eligibility guidelines for procedure code E0194, see Medical Policy Bulletin E-12, Beds-Accessories and Related Items.
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| E0431 |
Portable gaseous oxygen system, rental, includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing |
| E0434 |
Portable liquid oxygen system, rental, includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing |
| E0439 |
Stationary liquid oxygen system, rental, includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing |
| E0445 |
Oximeter for measuring blood oxygen levels non-invasively
- NOTE:
- For eligibility guidelines for this device, see Medical Policy Bulletin E-25, Pulse Oximetry Device.
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| E0450 |
Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube) |
| E0460 |
Negative pressure ventilator; portable or stationary |
| E0461 |
Volume control ventilator, without pressure support mode, may include pressure control mode, used with non-invasive interface (e.g., mask) |
| E0463 |
Pressure support ventilator with volume control mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube) |
| E0464 |
Pressure support ventilator with volume control mode, may include pressure control mode, used with non-invasive interface (e.g., mask) |
| E0471 |
Respiratory assist device, bi-level pressure capability, with backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)
- NOTE:
- For additional eligibility guidelines for procedure code E0471, see Medical Policy Bulletin E-34, Respiratory Assist Devices.
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| E0472 |
Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device)
- NOTE:
- For additional eligibility guidelines for procedure code E0472, see Medical Policy Bulletin E-1, Durable Medical Equipment.
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| E1390 |
Oxygen concentrator, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate. |
| E1391 |
Oxygen concentrator, dual delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate, each |
| K0671 |
Portable oxygen concentrator, rental
- NOTE:
- For additional eligibility guidelines for procedure codes E1390, E1391, and K0671 see Medical Policy Bulletin E-11, Oxygen Concentrators and Related DME.
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Text Attachment
Procedure Code Attachment
Glossary
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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.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
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