Durable Medical Equipment (DME) Coverage Policy
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Policy governing medical necessity, coverage, rental vs purchase, maintenance/repair/replacement, and upgrade rules for durable medical equipment for Blue Cross Blue Shield of North Carolina members and their DME suppliers.
A number of HCPCS/other billing codes were added or updated over time (examples: K0743-K0746, K0900, Q0477, E1012, E1629, K0739-K0740, S9002, and planned addition of C9811/C9815/C9816 effective 1/1/26).
Description of DME expanded for clarification and wording adjustments made in When Covered and Not Covered sections (e.g., removal of phrase 'within the scope of his license' and later replacement with 'licensed provider' then 'provider/other professional provider').
Related reimbursement policies and guidance were added to the Related Policies section (examples: Facility Billing Requirements, Supply and Equipment Reimbursement, Modifier Guidelines, Speech Generating Devices).
Coverage Criteria for Durable Medical Equipment
When Durable Medical Equipment and Services are covered
Durable medical equipment may be covered when ALL of the following are met:
See policy guideline requiring prescription to rent or purchase (Policy Guidelines).
DME Medical Necessity
Medical necessity for DME requires ALL of the following:
Prescription required to rent or purchase per Policy Guidelines.
Items primarily for comfort or convenience are considered not medically necessary.
Examples include environmental control equipment (air conditioners, humidifiers, air filters).
Maintenance, Repairs, and Replacement
Maintenance, repair, and replacement rules differ by ownership:
Coverage for maintenance/service agreements is subject to the provider’s contracted terms.
Payment of eligible fees begins on day device is delivered, set‑up, and ready for use.
Rental vs Purchase Criteria
Rules for rental vs purchase and purchaseability categories:
Examples include canes, walkers, crutches, slings, peak flow meters, commode chairs.
Examples include low pressure pads, home glucose monitors, braces, Jobst stockings.
Rental trial may be required to document benefit and applied toward purchase price.
Rental continues until purchase price cap is met; purchased equipment without prior rental is owned by the member.
DME Add-ons or Upgrades Coverage
Coverage stance for add‑ons/upgrades:
Delivery, set‑up, education/training and nursing visits are not eligible for separate reimbursement regardless of rent or purchase.
Examples of items excluded as DME add-ons or upgrades include those that are intended primarily for convenience or luxury beyond what is necessary to meet the member’s legitimate medical needs (for example, decorative items, unique materials, lights, extra batteries).
Items that do not provide therapeutic benefit, items that have not been prescribed by a provider or other professional provider, and items that serve primarily as comfort or convenience (for example, trays, backpacks, wheelchair racing equipment) are not covered.
Equipment used to enhance the environmental setting (for example, air conditioners, humidifiers, air filters, portable Jacuzzi pumps, chair lifts) and items provided by a facility that is expected to supply them are not eligible for DME coverage.
Delivery, set-up, education/training for member/family, and nursing visits are not eligible for separate reimbursement regardless of whether the equipment is rented or purchased.
Per the policy’s Benefits Application updates, standard mattresses are considered an item of convenience or comfort and therefore are not covered as durable medical equipment when assessed under the member’s benefit.
Standard mattresses and similar items that primarily provide comfort rather than therapeutic benefit are listed among non-covered items and should be evaluated against the member’s benefit booklet for any exceptions.
The policy defines items that are not medically necessary/not covered to include those that serve primarily as comfort or convenience, items with significant non-medical uses, and add-ons or upgrades that do not provide therapeutic benefit.
Examples of such non-covered add-ons/upgrades include decorative or cosmetic enhancements, accessories that do not significantly enhance device functionality, and environmental devices that are not primarily medical in nature.
Billing and Coding
| E0100-E0948 | |
| E1300-E1310 | |
| E1500-E2120 | |
| E2402-E2599 | |
| E8000-E8002 | |
| K0739-K0740 | |
| K0743-K0746 |
| K0743 | HCPCS code added/mentioned |
| K0744 | HCPCS code added/mentioned |
| K0745 | HCPCS code added/mentioned |
| K0746 | HCPCS code added/mentioned |
| K0900 | HCPCS code added 7/1/13 |
| Q0477 | HCPCS code added effective 1/1/18 |
| E1012 | HCPCS code added effective 1/1/16 |
| E1629 | HCPCS code added effective 1/1/22 |
| K0739 | HCPCS code added/mentioned |
| K0740 | HCPCS code added/mentioned |
Provider Actions and Authorization
Use listed HCPCS/CPT codes — inclusion ≠ guaranteed reimbursement
Applicable HCPCS/CPT codes are listed in the policy; inclusion of a code does not guarantee reimbursement. Suppliers must follow contractual billing and, when applicable, prior authorization processes for items mapped to these codes (examples include C9811, C9815, C9816, E0100-E0948, E1012, E1300-E1310, E1399, E1500-E2120, E1629, E2402-E2599, E8000-E8002, K0455, K0462, K0739-K0740, K0743-K0746, K0900, Q0477, S9002).
- Inclusion of a code in the Billing/Coding section does not guarantee reimbursement.
- Suppliers should follow contractual and prior authorization processes when applicable for items represented by listed HCPCS/CPT codes.
Verify benefits and obtain required prior authorization
Verify member benefits, eligibility, and any required prior authorization with the payer and the member’s contract before providing DME; this medical policy is informational only and is not an authorization or explanation of benefits.
- Benefits and eligibility are determined by the group contract and subscriber certificate in effect at the time services are rendered.
- Confirm prior authorization requirements and coverage applicability with the payer prior to service.
Document rental trial applied toward purchase for higher-cost DME
When purchase of more expensive DME is considered, document that a rental trial (with rental payments applied toward purchase price) was completed and that it demonstrated member compliance, tolerance, and clinical benefit prior to approving purchase.
- Rental trial must be documented showing compliance, tolerance, and clinical benefits.
- Rental payments applied toward purchase price may be required before purchase is authorized for DME costing above $200.
Operational billing actions — delivery, set-up, and prorated rental fees
Follow operational and contractual billing rules: ensure device is delivered, set up, and ready for use before billing rental or purchase fees; prorate rental/maintenance fees when a full 30-day rental period is not used.
- Payment begins on the day the device is delivered, set-up, and ready for use at the required location.
- Calculate rental and maintenance fees on a prorated basis when a full 30 days are not utilized.
Obtain signed member agreement and supply complete clinical documentation
Obtain a signed, dated, written member agreement for any additional (non-covered) charges prior to delivery, and submit comprehensive clinical documentation for medical necessity review including the licensed provider’s plan of treatment, anticipated timeframe, predicted outcomes, provider supervision, and a detailed description of the member’s clinical and functional status; BCBSNC may request medical records.
- Signed, dated, written agreement from the member for additional charges must be obtained prior to delivery of non-covered items.
- Medical necessity documentation must include: licensed provider’s plan of treatment with anticipated timeframe; predicted outcomes (therapeutic benefit); licensed provider’s involvement in supervising use; and detailed clinical/functional status.
- BCBSNC may request medical records; letters of support alone are insufficient unless they contain all required information.
Check Billing/Coding and related policies before claims submission
Reference the Billing/Coding section for current HCPCS codes when submitting claims and consult related reimbursement policies (e.g., Facility Billing Requirements, Supply and Equipment Reimbursement, Modifier Guidelines, Speech Generating Devices) for additional billing or documentation instructions.
- Check the policy’s Billing/Coding section for the most current HCPCS/CPT codes before claim submission.
- Review related policies for supplemental billing, reimbursement, or documentation rules.
Denial triggers — prescription, convenience, non-medical use, facility-supplied items
Denials may result if the item is not prescribed, serves primarily as comfort/convenience, has significant non-medical uses, is an add-on/upgrade intended mainly for convenience, or when devices are provided in a facility expected to supply them.
- DME must be prescribed by a provider or other professional provider to be eligible.
- Items intended primarily for convenience or that do not provide therapeutic benefit are not covered.
- Environmental or non-medical equipment (e.g., air conditioners, humidifiers, air filters) and facility-provided items are not eligible.
Confirm benefits and eligibility per member’s contract
Confirm benefits and eligibility with the payer and the member’s contract before applying medical policy; lack of coverage under the group contract or subscriber certificate in effect at the time of service may lead to denial.
- Medical policy is informational only and does not substitute for benefit/eligibility verification.
- Benefits are determined by the group contract and subscriber certificate effective at the time services are rendered.
Medical Necessity Definitions and Standards
DME Standardization
Definitions distinguishing standard versus non‑standard DME:
Rental, Purchase, Maintenance, and Replacement Rules
| Item | Rental rules | Purchase rules |
|---|---|---|
| General rule | ||
| When rented, coverage is based on item, prognosis, timeframe, and total rental vs purchase cost; rental fees cover maintenance, repairs, replacements, supplies/accessories, delivery/set-up, education/training, and nursing visits (these services are not eligible for separate reimbursement). Rental payment stops when cumulative rental reaches purchase price; equipment remains with DME provider and provider may then charge maintenance if contract signed. | ||
| When purchased, ownership transfers to member; purchased items may be eligible for separate reimbursement for maintenance/repair under a contracted maintenance fee with the DME supplier. Replacement of purchased items may occur when irreparably damaged or during repair/maintenance; repair costs exceeding replacement cost are not payable for the excess. |
| Purchased DME provision | Details |
|---|---|
| Maintenance and repair reimbursement | |
| Maintenance, repair, or replacement and supplies are eligible for separate reimbursement under a contracted maintenance fee with a DME supplier acceptable to the Plan; repair charges may include loaner equipment when necessary. | |
| Replacement and limits | |
| Replacement of a purchased item may occur when the item is irreparably damaged or if replacement is required during repair/maintenance. If repair expense exceeds estimated expense of purchasing or renting another item for the remaining period of need, no payment is made for the excess amount. Coverage for maintenance/service agreements is subject to the terms of the provider’s contracted maintenance agreement. |
| Topic | Historical notes / edits |
|---|---|
| Removal of specific examples | |
| {"text":"The Rental versus Purchase section had the " + "ROHO cushion" + " removed from item examples in earlier revisions (12/11/06 documentation of edits).", "status":""} | |
| Terminology changes | |
| Over multiple updates the policy wording was clarified (e.g., deletions and changes to provider phrasing) and Billing/Coding references were updated with added HCPCS codes (examples added in later updates). |
Exclusions and Non-Covered Items
Add-ons or upgrades intended primarily for convenience or luxury beyond what is necessary to meet the member’s medical needs are not covered.
Items that do not provide therapeutic benefit, items that have not been prescribed by a provider, and items that serve primarily as comfort or convenience (for example, trays, backpacks, decorative additions, racing equipment) are not covered.
Equipment used to alter or enhance the environment (for example, air conditioners, humidifiers, air filters, portable Jacuzzi pumps, chair lifts) are not considered primarily medical and are excluded from coverage.
Services such as delivery, set-up, education/training, and nursing visits are not eligible for separate reimbursement regardless of rental or purchase status.
Standard mattresses are explicitly identified as items of convenience or comfort and therefore are not covered under this DME policy when considered in that context.
Providers and suppliers should confirm member benefits and refer to the member’s benefit booklet for any plan-specific exceptions related to mattresses.
Documentation Requirements
Require signed member agreement plus provider documentation for medical necessity review
Supplier must obtain a signed, dated, written agreement from the member for additional charges prior to delivery of non‑covered items, and medical necessity documentation submitted for review must include the licensed provider’s plan of treatment, anticipated timeframe, predicted outcomes, provider involvement, and detailed clinical/functional status; BCBSNC may request medical records.
- Signed written agreement is required before delivery of non‑covered items.
- Include full provider documentation to support medical necessity; BCBSNC may request supporting medical records.
Check current HCPCS codes and related policies before submitting claims
Before billing or coding claims, providers should check the Billing/Coding section for the current HCPCS codes listed in this policy and consult the Related Policies (such as Facility Billing Requirements and Supply and Equipment Reimbursement) for additional billing and reimbursement information.
- Billing/Coding section contains applicable codes; verify updates (codes have been added/updated over time).
- Related Policies may affect claim submission and reimbursement rules.
Background
Durable medical equipment (DME) is equipment that provides a therapeutic benefit, is primarily and customarily used to serve a medical purpose, is reusable, and is ordered by a provider for use in the home or appropriate setting.
Typical examples of DME include wheelchairs (manual and power), hospital beds, oxygen and ventilators, monitors, pressure mattresses, lifts, nebulizers, and other devices that are primarily medical in purpose and not useful in the absence of illness or injury.
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