CurrentAnthemPolicy G-06052

Reimbursement Policy Durable Medical Equipment (Rent to Purchase)

Defines Anthem/AMH Health reimbursement rules for rented durable medical equipment (DME), including rent-to-purchase and capped rental limits, applicable to professional claims and providers submitting HCPCS-coded DME claims.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Durable Medical Equipment (Rent to Purchase)

Policy CodePolicy G-06052

Change TypeClarification; Administrative review

Effective Date10/6/2025

Next Review Date

Key ActionSubmit DME claims with applicable HCPCS codes and modifiers and ensure services meet authorization and medical necessity guidelines.

SourceLink

POLICY UPDATE CHANGES

Updated language, added clarification language for oxygen rental and oxygen supplies.

Review approved and effective: no changes (10/06/2025).

13standard max rental (months)

36oxygen equipment (months)

24oxygen supplies (additional)

G-06052policy id

Coverage Criteria for Rented Durable Medical Equipment

Coverage criteria for rented DME

Reimbursement is allowed for rented Durable Medical Equipment (DME) when all of the following criteria and limits are met; exclusions and special rules (particularly for oxygen) apply.

Claims must be professional DME claims submitted with the applicable HCPCS code(s) and any required modifier(s).

Reimbursement is based on the rental price up to the maximum allowed for the particular DME; the item is considered purchased once the purchase price has been met.

ALL of the following

Standard rental reimbursement limit is 13 months; once the limit is met, rental claims for the item are not eligible for reimbursement.
A break in coverage of more than 60 days restarts the rental limitation count.

Policy Summary

PayerAnthem

PolicyReimbursement Policy Durable Medical Equipment (Rent to Purchase)

Policy CodePolicy G-06052

Change TypeClarification; Administrative review

Effective Date10/6/2025

Next Review Date

Key ActionSubmit DME claims with applicable HCPCS codes and modifiers and ensure services meet authorization and medical necessity guidelines.

SourceLink

On This Page

ALL of the following

Excluded item types: Items not considered DME include prosthetics or orthotics and disposable medical supplies (DMS).
Nonreimbursable circumstances
- Provision of DME that exceeds the benefit limit unless authorized through medical necessity.
- Repair or replacement of DME necessitated by abuse or neglect.
- Repair or replacement of DME during the warranty period.
- Enhancements or upgrades of DME for the convenience of the member or caregiver.
- Aesthetic appearance upgrades based on member or caregiver preference.
- DME considered experimental or investigational.
- Purchase or rental of common household items that are not medically indicated.
- DME provided by a skilled nursing facility (SNF) — normally included as part of the facility charge and not separately reimbursable unless specified in a provider contract.

Coding and Rental Month Limits

HCPCS requirementHCPCS

Standard correct coding applies; DME claims must be submitted with applicable HCPCS code(s) and applicable modifier(s) appended.

Rental month limits

General capped rental13 months maximum rental reimbursement for rented DME; rental periods with a break in coverage >60 days reset the limitation count

Oxygen equipmentUp to 36 months monthly rental reimbursement for oxygen equipment

Oxygen contents and suppliesContinued reimbursement for oxygen contents and supplies for an additional up to 24 months (considered all‑inclusive with oxygen rental)

Claims Submission and Authorization

Prior Authorization

Claims submission, coding, and authorization requirements for rented DME

Submit all DME claims with the applicable HCPCS code(s) and any required modifiers; bill using CPT, HCPCS, and/or revenue codes that are fully supported in the medical record. Ensure services meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member’s state of residence. Reimbursement for rented DME is based on the rental price up to the maximum allowed and the item is considered purchased once the purchase price has been met.

All DME claims must be submitted with applicable HCPCS code(s) and applicable modifier(s).
Use industry-standard CPT, HCPCS, and/or revenue codes supported by medical records or office notes.
Services must meet authorization and medical necessity guidelines appropriate to procedure, diagnosis, and member’s state of residence.
Reimbursement is based on the rental price up to the maximum allowed; item is considered purchased once purchase price is met.

Definitions

Durable Medical Equipment (DME) definition

DefinitionDurable Medical Equipment (DME): Items primarily and customarily used to serve a medical purpose rather than convenience or comfort; can withstand repeated use; generally not useful to a person without an illness or injury; appropriate for use in the home; prescribed by a licensed physician/practitioner. All requirements must be met before an item is considered DME.

CharacteristicsPrimarily medical purpose; repeatable use; not useful without illness/injury; home‑appropriate; requires prescription by a licensed practitioner.

ApplicabilityApplies to rented DME reimbursement rules and distinctions from non‑DME items (e.g., disposable supplies, prosthetics/orthotics as noted elsewhere in policy).

Rent-to-purchase definition

DefinitionRent‑to‑purchase: a time period where reimbursement is based on a monthly fee up to the amount at which the item will be considered purchased.

Reimbursement basisPaid as a monthly rental fee until cumulative rental payments reach the purchase threshold, at which point the item is considered purchased.

Claim implicationProviders should bill monthly rental charges until purchase price reached; policy distinguishes rent‑to‑purchase from direct‑purchase arrangements.

Capped rental definition

DefinitionCapped rental: an amount reimbursed on a monthly rental basis that will not exceed the applicable number of continuous months; billing beyond the maximum months will not be reimbursed.

Continuous months ruleThe cap applies to continuous rental months; breaks in coverage greater than 60 days restart the rental limitation count (per related rental rules).

Nonreimbursable billingIf service is billed beyond the maximum number of rental months, no additional reimbursement will be allowed.