Mountain State Medical Policy Bulletin
Section: Durable Medical Equipment
Number: E-1
Topic: Durable Medical Equipment (DME)
Effective Date: October 1, 2006
Issued Date: October 2, 2006
Date Last Reviewed: 10/2006

General Policy Guidelines

Indications and Limitations of Coverage

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.

Procedure Codes

A4210A4211A4265A4458A4465A4490
A4495A4500A4510A4520A4554A4615
A4616A4630A4640A4927A4928A4930
A4931A4932A6410A6411A6412A6501
A6502A6503A6504A6505A6506A6507
A6508A6509A6510A6511A6512A6513
A6530A6531A6532A6533A6534A6535
A6536A6537A6538A6539A6540A6541
A6542A6543A6544A6549A7005A7006
A7017A9281A9300A9901E0100E0105
E0110E0111E0112E0113E0114E0116
E0117E0118E0130E0135E0140E0141
E0143E0144E0147E0148E0149E0160
E0161E0162E0163E0164E0165E0166
E0168E0170E0171E0172E0188E0189
E0190E0200E0202E0205E0210E0215
E0217E0225E0235E0238E0239E0240
E0241E0242E0243E0244E0245E0246
E0249E0315E0325E0326E0460E0472
E0480E0481E0482E0483E0484E0500
E0570E0574E0575E0580E0585E0600
E0602E0605E0606E0610E0615E0625
E0637E0638E0641E0642E0701E0705
E0745E0746E0761E0830E0840E0849
E0850E0855E0860E0870E0880E0890
E0900E0910E0911E0912E0920E0930
E0935E0940E0941E0942E0944E0945
E0946E0947E0948E1031E1035E1037
E1038E1039E1300E1310E1399E1700
E1701E1702E2000E8000E8001E8002
G0249S8185S8265S8270S8420S8421
S8422S8423S8424S8425S8426S8427
S8428S8429S8430S8431  

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

FEP will cover the rental or purchase, at our option, including repair and adjustment, of durable medical equipment.

Under this benefit, we cover:

  1. crutches
  2. walkers
  3. continuous passive motion (CPM)
  4. compression stockings

Non-covered items:

  1. car seats
  2. air conditioners, humidifiers, dehumidifiers, and purifiers

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

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

References

CMS Transmittal AB-02-136, CR 2371

NCD for Durable Medical Equipment Reference List (280.1)

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Table Attachment

 
TABLE A

COVERED

 

Item Additional Info
Accessories
(A4615, A4616, A4630, A4640)
NOT AN ALL INCLUSIVE LIST		 Reimbursement may be made for replacement of essential accessories such as hoses, tubes, mouthpieces, etc.., for necessary DME, only if the patient owns or is purchasing the equipment.
Antiembolism Stockings
(A4490-A4510)
(Surgical Leggings, e.g., Aero-Pulse Surgical Leggings, TEDS)		 Covered if prescribed by a physician and medically necessary for treatment of illness or injury, e.g., bedridden patients. Payment is limited to three pairs in a six-month period.
Canes
(E0100, E0105)		 Covered if patient's condition impairs ambulation.
Commode Chair-on-Wheels
(E0164, E0166, E0168)		 Covered.
Commode Chair with Seat Lift Mechanism
(E0170, E0171, E0172)		 Covered when all the following criteria are met:
  • The patient is confined to bed or room. (See Commodes)
  • The item is prescribed by a physician for a patient with severe arthritis of the hip or knee and for patients with muscular dystrophy or other neuromuscular diseases when it has been determined that the patient can benefit therapeutically from use of the device. These claims will be referred for medical review/individual consideration.
Commodes
(E0163, E0165, E0168)		 Covered if patient is confined to bed or room. Note: The term "room confined" means that the patient's condition is such that leaving the room is medically contraindicated. The accessibility of bathroom facilities generally would not be a factor in this determination. Confinement of a patient to his or her home in a case where there are no toilet facilities in the home may be equated to room confinement. Moreover, payment may also be made if a patient's medical condition confines him or her to a floor of his or her home and there is no bathroom located on that floor.
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)		 Continuous Passive Motion devices are covered as DME 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.

See Medical Policy Bulletin V-23 for information on CPM devices for temporomandibular joint dysfunction (TMJ).
Crutch, underarm, articulating, spring assisted
(E0117)		 Covered for patients with Spina Bifida (741.00-741.03, 741.90-741.93), Cerebral Palsy (343.0-343.9, 344.8), or spinal cord injury.
NOTE: For other conditions, individual consideration will be offered.

Crutch substitute, lower leg platform, with or without wheels, each
(E0118)

 Covered when determined to be medically necessary.
Crutches
(E0110-E0116)		 Covered if patient's condition impairs ambulation.
Eye pads/patches
(A6410, A6411, A6412)		 Covered for conditions such as strabismus (378.0-378.18, 378.5-378.73)
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.
Gradient Compression Stockings
(A6530-A6549)		 Covered if prescribed by a physician and medically necessary for treatment of illness or injury, e.g., ambulatory patients. Coverage is limited to three pairs or six single stockings in a six-month period.
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)
Heating Pads
(E0210, E0215, E0217, E0238, E0249)
(Aquamatic K-Pad)		 Covered when a medical review determines patient's medical condition is one for which the application of heat in the form of a heat pad is therapeutically effective.
Heat Lamps
(E0200, E0205)		 Covered when a medical review determines patient's medical condition is one for which the application of heat in the form of a heat lamp is therapeutically effective.
Helmet with face guard and soft interface material, prefabricated
(E0701)		 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.
Home Prothrombin Time INR Monitoring Device
(CoaguCheck, ProTime)
(G0249)		 Covered for patients who have a mechanical heart valve(s)(V43.3) and are receiving anticoagulant therapy. Special consideration may be given in individual situations for homebound patients receiving anticoagulant therapy who do not have a mechanical heart valve, when visits to a laboratory for prothrombin time testing are not possible due to the patient’s medical condition.
Hydrocollator Steam Packs Covered under same condition as a heating pad. Payment will be made at the amount for an ordinary heating pad. (Refer to Heating Pads)
Injectors and Injection Aid Devices
(hypodermic jet pressure powered devices for injection of insulin and supplies for self-administered injections)
(A4210, A4211)		 Covered for patients who are unable to use a syringe. See Medical Policy Bulletin B-46, 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.
Jaw Motion Rehabilitation System
(E1700-E1702)
(Therabite)		 Covered when prescribed by a physician.
Lambs Wool Pads
(E0188-E0189)		 Covered if patient has, or is highly susceptible to, decubitus ulcers; and patient's physician has specified that he or she will be supervising its use in connection with his or her course of treatment.
Muscle Stimulators
(Orthopedic-related uses only)
(E0745)		 Covered for treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non-neurological reasons for disuse are causing atrophy. Some examples would be casting or splinting of a limb, contracture due to scarring of soft tissue as in burn lesions, and hip replacement surgery (until orthotic training begins).
Nebulizers
(A7005, A7006, A7017, E0570, E0580-E0585)
(Maxi-Mist, Puritan Compressor Aerosol Unit, Respirizer)		 Covered if patient's ability to breathe is severely impaired.
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.
Non-elastic Binders for Extremities
(Circ-aid, MedAssist, Reid Sleeve, Tribute)
(A4465, S8420-S8431)		 Covered for lymphedema (457-457.9, 757.0).
Osci-Lite Covered under same conditions as Heat Lamps.

Oscillatory Devices
Cough Stimulating Device (e.g., In-Exsufflator)(E0482)
Flutter (S8185)
Intrapulmonary Percussive Ventilation System (e.g., Percussionaire)(E0481)
Oscillatory positive expiratory pressure device, non-electric, any type, each
(E0484)

 

High Frequency Chest Wall
Oscillation Air-Pulse Generator System (includes hoses and vest), each
(E0483)
(e.g., ABI Vest Airway Clearance System, Thairapy Vest)

Oscillatory devices (e.g., Flutter, In-Exsufflator, Percussionaire, Thairapy Vest) are alternatives to conventional percussors. They are designed to provide self-administered airway clearance. Oscillatory devices are covered for mobilizing secretions in patients with pulmonary conditions that limit the ability to expectorate secretions. (See Percussors)

 

 

Benefits are provided for a high frequency chest wall oscillatory vest device only when all of the following criteria are met:

  1. A diagnosis of moderate to severe cystic fibrosis.
  2. Prescribed by a pulmonary specialist.
  3. Recent pulmonary function studies demonstrating:
    • FEV1 less than 80% of predicted,
    • FVC less than 50% of predicted, and
    • 25% decrease on small airway score over one (1) year
  4. Multiple admissions with a diagnosis of respiratory distress involving inability to clear mucus effectively from the respiratory tract.
  5. Documentation exhibiting a lack of success in using chest physiotherapy or respiratory therapy using a flutter link, or documentation that family members or other caregivers are unavailable or unable to provide effective chest therapy.

 
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 week, documentation of medical necessity is required.
Postural Drainage Boards
(E0606)		 Covered if patient has a chronic pulmonary condition.
Quad Canes
(E0105)		 Covered if patient's condition impairs ambulation.
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 5 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, all claims will be referred for medical review/individual consideration.
Self-Contained Pacemaker Monitor
(E0610, E0615)
(Audible/Visable 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 or her 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.
Suction Machine
(E0600, E2000)		 Covered if the medical staff determines that the machine specified in the claim is medically required and appropriate for home use without technical or professional supervision.
Surgical Mask
(A4928)		 Covered when medically necessary and used in the home.
Therapeutic Fomentation Device Covered under same conditions as heating pad. Payment will be limited to the amount payable for an ordinary heating pad. (Refer to Heating Pads.)
Thermometers
(A4931, A4932)		 Covered for chronic renal failure (585.6) when submitted with modifier AX, indicating that the item is being furnished in conjunction with dialysis services.
Traction Equipment
(E0840-E0900, E0920, E0930, E0941, E0942, E0944-E0948)

Covered if patient has orthopedic impairment requiring traction equipment which prevents ambulation during the period of use.
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.
Trapeze Bars
(E0910, E0911, E0912, E0940)		 Covered if patient is bed confined and the patient needs a trapeze bar to sit up because of a respiratory condition, to change body position for other medical reasons, or to get in and out of bed.
Ultrasonic Nebulizer
(E0574-E0575)		 Covered only where patient is unable to clear bronco-pulmonary secretions using a standard nebulizer or when used by a patient with cystic fibrosis.
Urinals
(autoclavable hospital type)
(E0325, E0326)		 Covered if patient is bed confined.
Vaporizers
(E0605)		 Covered if patient has a respiratory illness.
Walkers
(E0130-E0149)		 Covered if patient's condition impairs ambulation.
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 will be limited to the cost of providing the services elsewhere, e.g., an outpatient department of a participating hospital, if that alternative is less costly. All claims will be referred 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

Items on this table do not meet the definition of DME. Therefore, they are benefit denials and are billable to the member.
Item Additional Info
American Bidet Toilet Seat
(Bidet Toilet Seat)		 Hygienic equipment
American Sonoid Heat and Massage Foam Cushion Pad  
Auto-Tilt Chair
(Autolift)		  
Bathtub Lifts
(E0625)
(Autolift)		  
Bathtub/Shower chairs/Seats
(E0240)
(Easton E-Z Bath, Tub Chair)		 Hygienic equipment
Carafes  
Communic-Aid  
Communicator  
Elevators
(Stairglide, Stairway Elevators, Wheel-O-Vator)		  
Emesis Basins  
Enuresis (Bed Wetting) Alarm
(S8270)
Heavy Cast Socks-6 Hygienic supply
Incontinence Supplies
(A4520, A4554)		 Supplies such as incontinence garments (e.g., brief, diaper)(A4520) and underpads (A4554) are nonreusable supplies, hygienic equipment; not primarily medical in nature. Exceptions to coverage for these devices are identified in the individual group's benefits.
NOTE: These items are not part of a urinary collection system.
Light Cast Sock-6 Hygienic supply
Massage Devices
(Cos-Medic Automasseur)		 Considered comfort items not generally accepted by the medical profession as either medically indicated or effective.
Moore Wheel Exercise equipment
Niagara Massage Pillow  
Niagra Thermo-Cyclopad  
Nolan Bath Chair Hygienic equipment
Overtoilet Commode Hygienic equipment
Pacex Precautionary in nature; does not serve a clearly identifiable diagnostic or therapeutic purpose.
Portable Whirlpool Pumps
(E1300)
(Action Bath Hydro Massage, Aero Massage, Aqua Whirl, Aquasauge, Hand-D-Jet, Hydro Jet, Jacuzzi, McKune, Thermo Jet, Turbo-Jet, Whirl-A-Bath, Whirl-O-Matic, Whirlpool Pumps)		 Do not primarily and customarily serve a therapeutic purpose; generally used for soothing or comfort purposes.

Environmental control equipment not medical in nature.
Positioning Support System
(Oakworks Support System)		 A support system may include a face support, a seated support and accessories, e.g., pillow covers and arm rests. Also available may be a carrying case for transporting device components. A device may be obtained directly from the manufacturer and is returned following use. Therefore, a positioning support system is rented, not purchased, and separate shipping and handling fees may be billed with the fee for the rental of the device.

The positioning support system is not eligible for reimbursement as it is primarily a patient convenience device to assist in maintaining a suggested postoperative position following surgery, such as vitrectomy and repair of a retinal tear via intraocular gas.

However, approval of the system or specific components of a system may be given when a medical condition, such as severe cervical arthritis (721.0), causes difficulty in maintaining the postoperative position. In these instances, approval should be limited to the component(s) of the system which most adequately meet the needs of the patient, and for no longer than a period of up to three weeks. Requests for longer periods of time should be reviewed on an individual consideration basis.
Raised Toilet Seats
(E0244)
(Burke Electric Portable Commode Erector, Burke Toilet Seat Erector)		 Hygienic equipment
Sauna Baths Used to improve appearance
Spare Deionization Supply Tank Precautionary supply
Standing Table
(E0315)		  
Telephone Alert Systems Do not serve a diagnostic or therapeutic purpose.
Telephone Arms  
Tub Stool or Bench
(E0245)
NOTE:
Code E1399, durable medical equipment, miscellaneous, should be applied to those procedures listed without a designated procedure code.
 
TABLE C

DENY
Environmental control equipment; not primarily medical in nature

Items on this table do not meet the definition of DME. Therefore, they are benefit denials and are billable to the member.
Item Additional Info
Air Cleaners
(Electric Air Cleaners, Electrostatic Machines, Honeywell Air Purifier, Micronaire Environmental Control, Selectronair)		  
Air Conditioners
(Electric Air Cleaners, Electrostatic Machines, Honeywell Air Purifier, Micronaire Environmental Control, Selectronair)		  
Dehumidifiers Room or central heating system types
Heating and Cooling Plants  
Humidifiers Room or central heating system types
Portable Room Heaters  
NOTE:
Code E1399, durable medical equipment, miscellaneous, should be applied to those procedures listed without a designated procedure code.
 
TABLE D

DENY
Inappropriate for home use

Items on this table do not meet the definition of DME. Therefore, they are benefit denials and are billable to the member.
Item Additional Info
Aquamatic K-Thermia Institutional type equipment
Autosfig Physician instrument
Circulator Institutional or physician type equipment
Diathermy Machines
(standard pulsed wave types)
(Diapulse Machine (E0761), Spectrowave Machine, Superpulse Machine, Theramatic Machine)		  
Electrocardiocorder Not covered as DME. (Home use may be covered only as a hospital or physician diagnostic service.)
Electromyography (EMG), Biofeedback Device
(E0746)		  
Esophageal Dilator Physician instrument
Hydrocollator Heating Unit
(E0225, E0239)
Medcolator  
Medco-Minalator  
Medco-Sonolator Twin  
Mobile Monomatic Sanitation System  
Oakes Controller Unit  
Paraffin Bath Units
(standard)		 Institutional type equipment
PORTABLE: See Table A.
Parallel Bars Support exercise equipment; primarily for institutional use; in the home setting other devices, e.g., a walker, satisfies the patient's need
Pulse Tachometer Not reasonable or necessary for monitoring pulse of homebound patient with or without a cardiac pacemaker.
Puritan Bennet MA-1 Respiration Unit
(Model No. 3700)		 Institutional type equipment
Telemedic II Not covered as DME. Home use may be covered only as an outpatient hospital or physician diagnostic service.
Tractomatic Electrical
Intermittent Traction Unit		  
Translift Chair Institutional type equipment
NOTE:
Code E1399, durable medical equipment, miscellaneous, should be applied to those procedures listed without a designated procedure code.
 
TABLE E

DENY
Nonreusable supply; not rental type item

Items on this table do not meet the definition of DME. Therefore, they are benefit denials and are billable to the member.
Item Additional Info
Catheters (non-urinary) Disposable supply. See "Coverage Status" information on Medical Policy Bulletin O-9 for urinary catheters.
Disposable Sheets and Bags  
Irrigating Kit Hygienic equipment
NOTE:
Code E1399, durable medical equipment, miscellaneous, should be applied to those procedures listed without a designated procedure code.
 
TABLE F

DENY
Not the customary practice to bill

Items on this table do not meet the definition of DME. Therefore, they are benefit denials and are billable to the member.
Item Additional Info
Delivery, Set-up and Service
(A9901)		  
Installation and Labor of Rented or Purchased Equipment Reimbursement may be made for labor necessary to repair equipment which the patient owns or is purchasing. Labor charges related to rented equipment will be denied. (NOTE: Installation, repairs, supplies and accessories for dialysis equipment may be paid regardless of whether the equipment is being rented or is purchased.)
Mileage  
NOTE:
Code E1399, durable medical equipment, miscellaneous, should be applied to those procedures listed without a designated procedure code.
 
TABLE G

DENY
Not primarily medical in nature

Items on this table do not meet the definition of DME. Therefore, they are benefit denials and are billable to the member.
Item Additional Info
Braille Teaching Texts Educational equipment
Ear Plugs (standard or custom-made)  
Electric Adaptor
(e.g., car/truck adaptor)
Enema/Enema Bags
(A4458)		  
Exercise Equipment
(A9300)		  
Exercycle Exercise equipment
Grab Bars
(E0241-E0243, E0246)
(Safety Grab Bars)		 Self-help device
Ice Pack  
Limb-O-Cycle  
Linen, nonallergenic  
Lumbar Roll  
Positioning cushion/pillow/wedge, any shape or size
(E0190)
Reaching/Grabbing device, any type, any length, each
(A9281)
Restorator Exercise equipment
Seat Tilt  
Silverware/Utensils  
Speech Teaching Machines
(Bell and Howell Language Master)		 Educational equipment
Strollers
(E1037, E1038, E1039)		  
Toilet Seats Not medical equipment
Treadmill Exerciser Exercise equipment
NOTE:
Code E1399, durable medical equipment, miscellaneous, should be applied to those procedures listed without a designated procedure code.

Text Attachment

Procedure Code Attachment


Glossary




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.