CurrentAnthemPolicy G-06052

Durable Medical Equipment (Rent to Purchase) reimbursement policy

Defines Anthem's reimbursement rules for rental and rent-to-purchase Durable Medical Equipment (DME), who may bill, and limits on rental periods and exclusions; applies to Anthem commercial and Medicare Advantage lines as noted in the header.

Policy Summary

PayerAnthem

PolicyDurable Medical Equipment (Rent to Purchase) reimbursement policy

Policy CodePolicy G-06052

Change TypeNo material changes

Effective Date10/06/2025

Next Review Date

Key ActionSubmit DME claims with applicable HCPCS code(s) and modifiers and ensure services meet authorization and medical necessity requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

13 monthsstandard reimbursement limit for rented DME

36 monthsoxygen equipment rental limit

24 monthsoxygen supplies additional reimbursement

All-inclusiveoxygen supplies included

No changesreview note

Durable Medical Equipment Rental Coverage

Policy Summary

PayerAnthem

PolicyDurable Medical Equipment (Rent to Purchase) reimbursement policy

Policy CodePolicy G-06052

Change TypeNo material changes

Effective Date10/06/2025

Next Review Date

Key ActionSubmit DME claims with applicable HCPCS code(s) and modifiers and ensure services meet authorization and medical necessity requirements.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

DME rental coverage criteria

Covered when ALL of the following are met:

The health plan allows reimbursement for professional claims billed for Durable Medical Equipment (DME) under specific guidelines, unless provider, state, federal, or CMS contracts and/or requirements indicate otherwise.

Claims must be submitted with the applicable HCPCS code(s) and have the applicable modifier(s) appended; standard correct coding applies and services should be supported by documentation.

Reimbursement for rented DME is limited to 13 months.

Rental periods that contain a break in coverage of more than 60 days will start the 13‑month limitation count over; a change of supplier during the rental period does not restart the rental period.

Oxygen equipment and supplies

Oxygen equipment is reimbursed on a monthly rental basis for a maximum of 36 months.
Supplies, contents, and accessory components associated with oxygen rental DME are considered all‑inclusive in the oxygen rental reimbursement and are not separately reimbursed; oxygen contents and supplies may be reimbursed up to an additional 24 months as applicable.

Reimbursement is based on the rental price up to the maximum allowed; the item is considered purchased once the purchase price has been met (rent‑to‑purchase/capped rental rules apply).

The health plan does not allow reimbursement for: DME that exceeds benefit limits unless authorized through medical necessity; repair or replacement necessitated by abuse or neglect; repair or replacement during the warranty period; enhancements or upgrades for convenience; aesthetic preferences; experimental or investigational DME; purchase or rental of common household items not medically indicated; and DME provided by a skilled nursing facility (unless provider contract states otherwise).

Coding and Reimbursement Limits

Coding expectationsCPT | HCPCS | Revenue

No codes listed

Rental reimbursement limits

Standard rented DME limitReimbursement limited to 13 months; once met, rental claims are not eligible for reimbursement

Oxygen equipment rental maximumOxygen equipment reimbursed on a monthly rental basis for up to 36 months

Oxygen contents and supplies reimbursementOxygen supplies/contents are considered all-inclusive in the oxygen rental reimbursement and may be reimbursed for an additional 24 months

Break in coverage ruleRental periods with a break in coverage >60 days will restart the limitation count

Supplier change ruleChanging suppliers during the rental period does not restart the rental period limitation

Billing, Authorization, and Provider Requirements

Billing Rule

Billing, coding, and authorization requirements for DME claims

Submit DME claims with the applicable HCPCS code(s) and applicable modifier(s); ensure services meet authorization and medical necessity guidelines and are fully supported by the medical record. Use CPT, HCPCS, and/or revenue codes as appropriate and follow proper billing and submission guidelines to avoid claim rejection, denial, recovery, or adjustment.

Append the applicable modifier(s) to HCPCS codes on all DME claims (per policy requirement).
Ensure services meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence.
Support billed CPT/HCPCS/revenue codes in the medical record and office notes to avoid rejection, denial, or recoupment.

Key Definitions

Durable Medical Equipment (DME)

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 without illness or injury; appropriate for home use; and prescribed by a licensed practitioner. All requirements must be met before an item is considered DME.

Primary useMust serve a medical purpose rather than convenience or comfort

DurabilityAble to withstand repeated use

Home use and prescriptionAppropriate for use in the home and prescribed by a licensed physician/practitioner

Rent-to-purchase

DefinitionRent-to-purchase: A time period where reimbursement is based on a monthly fee up to the amount that the item will be considered purchased.

Reimbursement basisMonthly rental fee applied until cumulative rental payments reach the purchase price

Purchase pointItem is considered purchased once the purchase price has been met via rental payments

Capped rental

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 yields no additional reimbursement.

Monthly capReimbursement limited to the applicable number of continuous months

Billing beyond capIf service is billed beyond the maximum rental months, no additional reimbursement will be allowed