Durable Medical Equipment (DME) coverage
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Defines medical necessity, prior authorization, rental/purchase, replacement, and exclusions for durable medical equipment for Blue Cross Blue Shield - North Carolina Medicare and related members.
Coverage Criteria
inv-01: General medical necessity
Covered when ALL of the following are met:
Based on Policy Statement and Indications for Coverage
inv-02: HMO member purchase exception (≤ $1,200 items)
For HMO members, items with contracted rate ≤ $1,200 will NOT require prior authorization if ALL are met:
Applies to HMO Members per Indications for Coverage
inv-03: PPO member purchase exception (≤ $1,200 items)
For PPO members, items with contracted rate ≤ $1,200 will NOT require prior authorization if ALL are met:
Applies to PPO Members per Indications for Coverage
inv-04: Replacement coverage
Replacement requests are covered when ANY of the following apply:
Replacement determinations consider manufacturer average life; RUL cannot be less than 5 years; warranty expiration alone is not sufficient justification
The following items are excluded as Over‑the‑Counter or personal comfort/convenience and are not covered: household fixtures/modifications and equipment with a non‑medical purpose such as electronic door openers, air cleaners, ramps, elevators, stair glides, and wheelchair attachments or bathtub/shower accessories. Also excluded are items specifically designed for outdoor use (for example, beach or rough‑terrain wheelchairs and manual sports wheelchairs), take‑home hospital items, professional fees related to dispensing/customizing (these are included in the overall charge), sales tax and mailing charges, and professional training in equipment use.
Add‑ons, upgrades, and duplicative equipment that exceed what is necessary to meet the member’s basic functional medical needs are not considered medically necessary and will not be approved. Examples include non‑standard or deluxe customizations primarily for comfort or convenience (e.g., customized wheelchair options, hand controls to drive, electric lifts for wheelchairs) and duplicative pieces of equipment intended as backup devices or for multiple residences, travel, work, or school (for example, a back‑up manual wheelchair when a power wheelchair is the primary mobility device). Consult the member’s Evidence of Coverage for plan‑specific rules regarding add‑ons/upgrades and duplicative equipment.
Medical Necessity
inv-17: General DME medical necessity
DME is covered when it is medically necessary and reasonable for treatment or function improvement and meets EOC limits.
See Description and Definitions
Coding and Authorization Thresholds
| A-codes | medical/surgical supply |
| B-codes | enteral and parenteral therapy |
| E-codes | Durable medical equipment |
| K-codes | Temporary codes |
| L-codes | Related to Orthotics |
| V-codes | Vision services |
Provider Actions and Prior Authorization
Obtain prior authorization for high‑cost and rental DME
Prior authorization is required for individual DME items with a contracted rate greater than $1,200; for all rental items (including rent‑to‑purchase); for all DME items prescribed by a non‑contracting physician for HMO members; and for individual support devices or supplies when the purchase price exceeds $1,200.
- Individual DME items with a contracted rate > $1,200 require prior authorization.
- All rental items require prior authorization, including rent‑to‑purchase items.
- All DME items prescribed by a non‑contracting physician require prior authorization (HMO members).
- Individual support devices and supplies require prior approval if purchase price is > $1,200.
Exceptions for items ≤ $1,200 when purchase conditions are met
Individual DME items with a contracted rate of $1,200 or less do not require prior authorization only when the specific conditions for HMO or PPO members are met (prescribing physician not excluded from Medicare, medically necessary, valid HCPCS, purchase only, and appropriate vendor contracting/certification).
- HMO exception conditions: prescribed by a physician not excluded from Medicare; medically necessary; provided by a provider/vendor contracted with the Plan; filed with a valid HCPCS code; item is for purchase only. (HMO members)
- PPO exception conditions: prescribed by a physician not excluded from Medicare; medically necessary; provided by a contracted or Medicare‑certified vendor; filed with a valid HCPCS code; item is for purchase only. (PPO members)
Episodic Care Manager may evaluate rental vs. purchase
An Episodic Care Manager evaluation may be required to determine whether items such as hospital beds, CPAP, wheelchairs, etc., should be rented versus purchased; rental is authorized for limited‑time use, frequent servicing, or when evaluation for long‑term use is needed.
- Episodic Care Manager may evaluate potential long‑term use versus immediate purchase for hospital bed, CPAP, wheelchair, etc.
- A rental item may be converted to purchase after two months if conversion is cost‑effective and member is expected to meet long‑term coverage criteria.
Supply complete clinical records and vendor information upon request
When the Plan requests medical records, include clinical documentation that supports medical necessity; letters of support or explanation may be helpful but are insufficient unless they contain all specific information needed to determine medical necessity. Provide supplier/vendor information as requested to establish that an item meets the DME definition and medical necessity.
- Provide clinical records and letters of support with the specific medical necessity details when requested.
- Include supplier/manufacturer and vendor information to demonstrate the item meets the DME definition and contract requirements.
Denial risk if prior authorization is not obtained
Failure to obtain required prior authorization may result in claim denial — this includes individual DME items with contracted rate > $1,200, all rental items (including rent‑to‑purchase), and DME prescribed by non‑contracting physicians for HMO members.
- Claims for items requiring prior authorization that do not have approval may be denied.
- HMO members: DME prescribed by a non‑contracting physician requires prior authorization; failure to obtain it may trigger denial.
Rental and Purchase Rules
| Equipment examples | When rental is authorized | When purchase may be authorized |
|---|---|---|
| Hospital bed, CPAP, wheelchair, etc. | Equipment used for a limited time; equipment that will require frequent servicing; equipment that requires evaluation by an Episodic Care Manager for potential long-term use versus immediate purchase. | When the equipment is customized; when immediate purchase is less expensive and long‑term rental is expected; when a rental item is converted to purchase after two months if cost‑effective and the member is expected to meet long‑term coverage criteria. |
| Rental item rule | Conversion to purchase |
|---|---|
| Rental is authorized for equipment used for a limited time; equipment that will require frequent servicing; and equipment requiring evaluation for potential long‑term use (e.g., hospital bed, CPAP, wheelchair). | A rental item may be converted to purchase after two (2) months if it will be more cost effective to do so and the member is expected to meet the criteria for long‑term coverage. |
Replacement and Useful Lifetime
inv-04: Replacement coverage (also listed under Coverage Criteria)
Replacement requests are covered when ANY of the following apply:
Replacement determinations consider manufacturer average life; RUL cannot be less than 5 years; warranty expiration alone is not sufficient justification
Documentation Requirements
Submit clinical records, detailed support letters, and vendor information when requested
Provide requested medical records, letters of support that include specific medical necessity details, and vendor/supplier information (including HCPCS code and manufacturer/model) to support DME determinations.
- Ensure letters include all specific information needed to make a medical necessity determination; otherwise they are not sufficient documentation.
- Include HCPCS code and vendor/contracting status when applicable.
Not Covered
Not covered under this policy are Over‑the‑Counter items, personal comfort or convenience items and their accessories, outdoor/specialty outdoor wheelchairs (e.g., beach or rough‑terrain chairs, sports wheelchairs), non‑medical home modifications and accessories, take‑home hospital items, professional dispensing/customization fees, items damaged due to abuse, and duplicative backup equipment intended for multiple residences, travel, or secondary use. Warranty expiration alone is not reasonable justification for replacement; replacement for damage not caused by normal wear and tear is excluded.
Definitions
Background
Durable Medical Equipment (DME) is equipment that is FDA‑approved or supported by clinical/manufacturer documentation, can withstand repeated use, is primarily and customarily used for medical purposes, is not generally useful in the absence of illness or injury, and is appropriate for use in the home. Coverage is provided when the item is medically necessary and reasonable to treat an illness or injury or to improve the function of a malformed body member, the member’s diagnosis warrants the equipment, and any applicable Evidence of Coverage limits are met.
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