Mountain State Medical Policy Bulletin
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

E0194E0431E0434E0439E0445E0450
E0460E0461E0463E0464E0471E0472
E1390E1391K0671   

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

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.
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.
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.
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.
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.

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.