Mountain State Medical Policy Bulletin
Section: Durable Medical Equipment
Number: E-10
Topic: Certificate of Medical Necessity (CMN)
Effective Date: August 1, 2005
Issued Date: August 1, 2005
Date Last Reviewed: 06/2005

General Policy Guidelines

Indications and Limitations of Coverage

For FEP only, all claims for the rental or purchase of durable medical equipment (DME) must include a certificate of medical necessity (CMN). If a claim is received for a DME item and the CMN is not provided, the claim will be denied. For all other products, a CMN is not required.

The continuing need for DME must be verified every 12 months. However, the period of need for certain conditions is considered indefinite. Generally, the conditions listed on the Text Attachment are permanent in nature, and the equipment will be needed for the rest of the patient's life. Therefore, claims for DME for these conditions do not require updated CMNs.

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).

Procedure Codes


Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

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Table Attachment

Text Attachment

Irreversible Conditions

Advanced arteriosclerotic heart disease (ASHD)
Advanced coronary artery disease (CAD)
AIDS
Alzheimer's disease
Amputee
Amyotrophic lateral sclerosis
Asthma, severe
Arthritis
Arthritis, rheumatoid or degenerative
Autism
Bronchiectasis
Buerger's disease
Cerebral palsy
Chronic cardiomyopathy
Chronic hepatitis
Chronic obstructive lung disease (C.O.L.D.)
Chronic obstructive pulmonary disease (C.O.P.D.)
Chronic renal disease
Congestive heart failure (CHF)
Crohn's disease
CVA with hemiparesis
Cystic fibrosis
Diabetes mellitus
Down's syndrome
Emphysema
Epilepsy
Gaucher's disease
Huntington's chorea
Hypoxia
Ileitis
Leprosy (Hansen's disease)
Leukemia
Lupus
Mental retardation
Metastatic cancer
Multiple sclerosis
Muscular atrophies
Muscular dystrophy
Myasthenia gravis
Neurofibromatosis
Organic brain syndrome
Osteogenesis imperfecta
Paget's disease
Paraplegia (hemiplegia)
Parkinson's disease
Polio
Progressive bulbar palsy
Psoriatic arthritis
Quadriplegia
Radiation fibrosis
Raynaud's disease
Retinitis pigmentosa
Sarcoidosis
Scleroderma
Sickle cell disease
Silicosis
Spina bifida
Thalassemia
Ulcerative colitis

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.