CurrentBlue Cross Blue Shield - WisconsinPolicy C-19007

DME Rent to Purchase - Professional

Reimbursement rules for professional claims billed for durable medical equipment (DME) on a rent-to-purchase basis, including rental limits, purchase conversion, maintenance/servicing, and nonreimbursable items; applies to providers submitting claims to Blue Cross Blue Shield - Wisconsin (as part of Anthem BCBS policies).

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyDME Rent to Purchase - Professional

Policy CodePolicy C-19007

Change TypeNo material change

Effective Date10/06/2025

Next Review DateN/A

Key ActionSubmit DME claims with applicable HCPCS code(s) and the required modifier; reimbursement is based on rental price up to the allowed purchase price or 10-month rental limit.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10-monthrental limit before purchase allowance met

2max maintenance reimbursements/yr

2units allowed per month (backup)

C-19007policy identifier

10/06/2025effective

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.

Rent-to-Purchase DME Coverage Criteria

Rent-to-Purchase DME coverage criteria

Reimbursement rules and exclusions for rent-to-purchase durable medical equipment (DME).

Reimbursement equals the rental price up to the health plan's allowance for the purchase price or the 10-month rental limit, whichever occurs first.

An item is considered purchased once the purchase price has been met; rental fees paid during a trial period are deducted from the purchase allowance.

When the health plan's allowance for a DME item changes during the rental period, the rental allowance for dates of service subsequent to the change will be calculated using the new allowance.

If there is a break in coverage of more than 3 months and rental resumes with the same DME provider, the original 10-month rental limit continues with the resumption month; if rental resumes with a different DME provider, the 10-month limit restarts at the resumption month.

If a member changes suppliers during a rental period, a new rental period will start over for the new supplier.

Maintenance and servicing: reimbursed equivalent to one month's rental allowance of the identified DME item, up to two times per year when appropriate modifier is appended; separate reimbursement for maintenance/servicing of 'Continuous Rental' items is allowed only when the item had been purchased prior to the effective date of the member's contract.

Allows rental of two units per month for DME that requires a back-up unit.

Nonreimbursable items and services (the plan does not allow reimbursement for):

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 rental period.
Routine repair and replacement of items classified by the plan as 'frequently serviced DME items'.
Enhancements or upgrades of DME for convenience or aesthetic preferences of the member or caregiver.
DME considered experimental or investigational.

Standard correct coding applies: all DME claims must be submitted with applicable HCPCS code(s) and have the applicable modifier appended unless provider, state, federal contracts indicate otherwise.

No exemptions to this policy are specified.

Administrative and Legal Statements

Administrative governance statements:

This policy is subject to applicable federal and state laws and to the terms, conditions, and limitations of a member's benefits on the date of service.

Reimbursement policies may be reviewed and updated periodically; the health plan reserves the right to review and update these policies.

No part of this publication may be reproduced, stored, or transmitted without permission from Anthem Blue Cross and Blue Shield.

Payer Entities and Jurisdiction Notes

Entity identification relevant to application:

Anthem Blue Cross and Blue Shield is a trade name used across multiple state-specific entities. In Wisconsin, Blue Cross Blue Shield of Wisconsin underwrites or administers PPO and indemnity policies and underwrites out-of-network benefits for certain POS policies.

Coding and Pricing Rules

Required codingHCPCS

HCPCS

Applicable HCPCS code(s) required on all DME claims; append applicable modifier as required.

Document identifiersmixed

No codes listed

inv-06: Rental-to-purchase threshold

Threshold descriptionReimbursement is calculated up to the health plan's allowance for the purchase price or the 10-month rental limit, whichever comes first; once the limit is met, rental claims receive no further reimbursement.

Effect of purchase during trialIf an item is rented for a trial period and then purchased, the rental fees paid during the trial period are deducted from the allowance for the purchase price.

Coverage break with same providerIf a rental period contains a break in coverage >3 months and resumes with the same DME provider, the 10-month rental limit continues with the resumption month.

Coverage break with different providerIf rental resumes with a different DME provider after a >3-month break, the 10-month RTP reimbursement limit restarts with the resumption month for the new provider.

Provider Billing and Usage Actions

Billing Rule

Claim submission and coding requirement

Submit DME claims with the applicable HCPCS code(s) and append applicable modifier(s) unless provider, state, or federal contracts/requirements indicate otherwise. Reimbursement is based on the rental price up to the maximum allowed for the specific DME; items are considered purchased once the purchase price has been met. Some items may be considered for direct purchase on a case‑by‑case basis.

Submit claims with applicable HCPCS codes and modifiers (unless overridden by contracts/regulations)
Reimbursement = rental price up to maximum allowed
Item considered purchased when purchase price met
Direct purchase may be approved on a case‑by‑case basis

Note

Use and Reproduction Restrictions

This policy is subject to applicable federal and state laws and to the terms, conditions, and limitations of a member's benefits on the date of service. Reimbursement policies may be reviewed and updated periodically. No part of this publication may be reproduced, stored, or transmitted in any form without permission from Anthem Blue Cross and Blue Shield.

Definitions

inv-09: Durable Medical Equipment (DME)

DefinitionDurable Medical Equipment (DME): Equipment that provides therapeutic benefits to a patient because of certain medical conditions and/or illnesses and that meets these criteria: primarily used for a medical purpose (not convenience), can withstand repeated use, generally not useful to a person without an illness or injury, appropriate for home use, and prescribed by a licensed physician/practitioner.

Typical characteristicsPrimarily and customarily used to serve a medical purpose; reusable and durable; prescribed for home use.

Clinical requirementMust be prescribed by a licensed physician/practitioner to qualify as DME.

inv-10: Purchase

DefinitionPurchase: Inexpensive items that are generally not reusable, are available for long-term use, and/or are customized.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyDME Rent to Purchase - Professional

Policy CodePolicy C-19007

Change TypeNo material change

Effective Date10/06/2025

Next Review DateN/A

Key ActionSubmit DME claims with applicable HCPCS code(s) and the required modifier; reimbursement is based on rental price up to the allowed purchase price or 10-month rental limit.

SourceLink

On This Page

Purchase or rental of common household items that are not medically indicated.

Cost of loaner equipment (included in repair/maintenance/servicing reimbursement).

DME rental items dispensed for use in a Place of Service other than the member's home.

DME provided by a skilled nursing facility (normally included as part of the facility charge) except specified SNF exceptions (hospital beds E0194, E0301–E0304; wound care items A6550, A7000; daily rental of E2402).

Shipping and handling fees, equipment delivery/set-up fees, and education/training for a member/family are not eligible for separate reimbursement.

Policy subject to member benefit terms and applicable federal/state laws
Policies may be reviewed and updated periodically
Reproduction, storage, or transmission of policy content requires permission

Items purchased outright rather than rented when they are inexpensive or customized for long-term use.

Reimbursement implicationPurchase items are treated differently than rental or rent-to-purchase items under the policy.

inv-11: Purchase/Rent to Purchase (P/RTP)

DefinitionPurchase/Rent to Purchase (P/RTP): Items not routinely purchased up-front; they are reusable, not service intensive, not customized, and/or may only be needed for short-term use.

Conversion ruleWhen a P/RTP item is purchased after rental trial, rental fees paid during the trial are deducted from the purchase allowance.

Rental cap interactionReimbursement for P/RTP items is limited by the health plan's purchase allowance or the 10-month rental limit, whichever occurs first.

inv-12: Continuous Rental

DefinitionContinuous Rental: Equipment which is never purchased and for which rental reimbursement is not capped at a purchase price; also referred to as 'frequently serviced' (FS) items and reimbursed as rentals for as long as medically necessary.

Reimbursement characteristicRental reimbursement for continuous rental items is uncapped and continues while medically necessary.

Alternate termAlso called 'frequently serviced' items.

inv-13: Daily Rental

DefinitionDaily Rental: Items considered short-term rentals, generally rented for less than a month.

Typical durationRented for brief periods, typically under one month.

Reimbursement implicationTreated as short-term rental items distinct from longer-term rent-to-purchase or continuous rental categories.

inv-14: Anthem/BCBS Affiliates and Usage

Trade nameAnthem Blue Cross and Blue Shield is the trade name used by multiple affiliated entities.

Wisconsin entityIn Wisconsin: Blue Cross Blue Shield of Wisconsin (BCBSWI) underwrites or administers PPO and indemnity policies and underwrites out-of-network benefits in certain POS policies.

Affiliates and global noteAnthem/BCBS affiliates vary by state; Anthem is a registered trademark of Anthem Insurance Companies, Inc., and independent licensees of the Blue Cross and Blue Shield Association operate in various states.