CurrentCapital BluecrossPolicy MP 6.026

Durable Medical Equipment and Supplies

Defines medical necessity, coverage, and item-specific coverage status for durable medical equipment and associated supplies for Capital BlueCross members; applies to providers ordering or supplying DME.

Policy Summary

PayerCapital Bluecross

PolicyDurable Medical Equipment and Supplies

Policy CodePolicy MP 6.026

Change TypeNo material change

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionVerify medical necessity and document continuing need at least every 12 months and ensure the prescribing provider is involved in ongoing care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

12 monthsminimum verification period for continuing need

30+DME items listed or referenced

E0433, E0431, E0441-E0444examples of HCPCS codes listed

Multiplepolicy history entries (2019-2025)

Coverage Criteria for Durable Medical Equipment

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General DME medical necessity

DME is covered when ALL of the following are met

DME general medical necessity: DME is medically necessary when it is expected to make a meaningful contribution to treatment of the patient's illness or injury or to improve function of a malformed part; ordered by a provider within the scope of their license; appropriate for use in the home; reusable; and primarily used to serve a medical purpose and not useful in the absence of illness or injury.

Continuing need must be verified at least every 12 months and the provider should have an established relationship and be involved in the ongoing care of the member.

Commode and bedpan criteria

Covered specific-item criteria examples

Commodes and bedpans: Commodes (including commode chairs on wheels) are covered when the individual is confined to bed or room; bedpans (autoclavable) are covered when the individual is bed confined.

'Room confined' means leaving the room is medically contraindicated; see policy definition.

Commode chair with seat lift mechanism: Covered when ALL of the following are met: the individual is confined to bed or room; and the item is prescribed for an individual with severe arthritis of the hip or knee or for individuals with muscular dystrophy or other neuromuscular diseases when therapeutic benefit is expected.

Associated HCPCS: E0170, E0172.

Ambulation devices

Ambulation aids

Crutches are covered when the individual's condition impairs ambulation.

Multiple HCPCS codes listed (E0110-E0116).

Crutch substitute (lower leg platform): Covered when ordered as medically necessary and only after bunionectomy or foot/ankle surgery when total non-weight bearing of the affected foot is required for 4–6 weeks.

HCPCS: E0118.

Underarm articulating spring-assisted crutch: Covered for individuals with spina bifida, cerebral palsy, or spinal cord injury.

HCPCS: E0117.

Gait trainers: Basic gait trainers are covered when ordered for individuals ≥ 2 years who require moderate to maximum support and have reciprocal motion capability and sufficient strength and alignment to support upright weight for prolonged periods.

Compression garment criteria

Compression garments/stockings

Gradient compression dressings/stockings: Gradient compression nonelastic wraps or stockings with pressure between 30 and 50 mm Hg are covered when prescribed for open venous stasis ulcers and/or surgically created wounds.30-50 mm Hg

Antiembolism (TED) stockings are covered to prevent or treat deep vein thrombosis and related conditions.

Oxygen and nebulizer coverage

Respiratory and oxygen equipment

Nebulizers: Small-volume, non-filtered nebulizers with compressor are medically necessary for administration of inhaled medications for pulmonary diseases (examples include chronic bronchitis, COPD, emphysema, asthma, COVID-19, bronchiectasis, persistent thick secretions, croup).

HCPCS examples: E0570, E0575, E0585, E0574, E0580.

Portable oxygen systems: Regulated (adjustable flow-rate) portable oxygen systems are covered (e.g., E0433). Preset (non-adjustable flow-rate) portable oxygen systems (e.g., E0431) are denied except for emergency or first-aid use.

See HCPCS distinctions in policy text.

Paraffin, traction, and other devices

Other device-specific criteria

Paraffin bath units (portable): Covered when the individual has undergone a successful trial period of paraffin therapy ordered by a provider and the condition is expected to be relieved by long-term use; includes coverage of paraffin consumables when the unit is medically necessary.

HCPCS: E0235.

Pneumatic cervical traction unit: Covered when prescribed by a provider or eligible provider within the scope of their license and the diagnosis is one or a combination of the specified cervical conditions. For certain diagnoses, coverage requires a documented trial of physical therapy.

HCPCS: E0860; diagnoses and trial requirements detailed in policy text.

Pneumatic cervical traction medical necessity

Items are covered when specific item-level criteria are met; examples below extract explicit criteria stated in this part of the document.

Pneumatic cervical traction unit (E0860): Covered when ALL of the following are met: prescribed by a provider or other eligible provider within the scope of their license; and the diagnosis is one or a combination of listed cervical conditions (examples include tension headache; cervical root lesions; cervical spondylosis without myelopathy; displacement of cervical disc; cervical disc degeneration; degeneration intervertebral disc; cervicalgia; cervical radiculopathy; cervicobrachial syndrome; osteoarthritis of the cervical spine); additionally, certain listed diagnoses are considered medically necessary only with a documented trial of physical therapy as specified in policy.N/A

Detailed list of allowable diagnoses and PT trial requirements provided in policy text.

Stander coverage criteria

Standers (non-powered standing frames) coverage criteria:

Standers (standing frames): Non-powered standers are medically necessary if ALL of the following are met: the individual has a neuromuscular disease resulting in inability to stand independently or ambulate despite use of other assistive devices and having undergone physical therapy or occupational therapy; AND the individual has sufficient lower-body residual strength to stand with the assistance of the standing system. Once standing, the individual must have the ability to ambulate.N/A

Referenced HCPCS: E0642, E0641, E0638, E0637.

Ventilator coverage and secondary ventilators

Ventilator coverage and multiple ventilators:

Ventilators (A4611–A4613): Ventilators are covered for treatment of neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to COPD (includes positive and negative pressure types). A second ventilator may be medically necessary when required to serve a different purpose as determined by the individual's medical needs (examples provided). Multifunctional ventilators that perform additional functions will not be covered in the same rental month as other single-function component devices.N/A

Examples and rental-month coordination guidance provided in policy text.

Portable oxygen system coverage

Portable oxygen systems:

Portable oxygen systems: Regulated (adjustable flow rate) portable oxygen systems are covered (E0433). Preset (flow rate not adjustable) portable oxygen systems (E0431) are denied for non-emergency/first-aid use.N/A

See coding distinctions (E0433 vs E0431) in policy text.

Paraffin bath unit coverage

Paraffin bath units:

Paraffin bath unit (portable): Covered when the individual has undergone a successful trial period of paraffin therapy ordered by a provider and long-term use is expected to relieve the condition; includes coverage of paraffin consumables when the unit is medically necessary.N/A

HCPCS: E0235.

Seat lift mechanism coverage

Seat lift mechanism coverage:

Seat lift mechanism: Covered when prescribed for severe knee or hip arthritis or severe neuromuscular disease and when prescribed to effect improvement, arrest or retard deterioration; the individual must be completely incapable of standing up from a regular chair in the home and must be able to ambulate once standing. Seat lift mechanisms that operate by spring-release with a sudden, catapult-like motion that jolts the standing position are considered investigational.N/A

Associated HCPCS: E0627, E0629 (and related lift codes listed in policy).

Specialized stroller coverage

Specialized strollers:

Customized pediatric strollers: Covered for a non-ambulatory child who requires more support than a standard pediatric wheelchair or is too small to safely use a standard pediatric wheelchair.N/A

No specific HCPCS code listed in policy.

Comfort or convenience items and environmental control equipment are not considered durable medical equipment for home medical benefit purposes and are listed as not covered. Examples include lounge or power beds, hot/ice packs, overbed tables, spare tanks of oxygen, air cleaners, room humidifiers or central HVAC systems, portable room heaters, and similar items that primarily serve comfort or environmental control rather than a medical treatment purpose.

Equipment that is not primarily medical in nature (for example, exercise equipment, certain strollers, bed lifters, positioning pillows) and items described elsewhere in the policy as inappropriate for home use (e.g., standard paraffin bath units when not the portable, medically necessary variety) are likewise excluded from coverage.

Patient lifts (hydraulic or motorized) are covered only when the provider determines they are medically necessary to effect improvement or prevent deterioration; however, lifts that require home structural modification are explicitly not covered. When multiple ventilators are under consideration, a second ventilator may be medically necessary if it serves a different purpose (examples provided), but note that multifunctional ventilators that perform additional functions (oxygen concentration, nebulization, aspiration, cough stimulation) will not be covered in the same rental month as single-function component devices.

Ventilator equipment is generally provided via rental rules in the policy; providers should follow the item-level guidance and prior authorization or documentation requirements as applicable when ordering patient lifts or ventilators.

Policy history documents administrative changes including a minor review on 02/15/2024 during which language referencing blood pressure cuffs was removed from this policy.

Replacement DME due to equipment misuse or abuse, loss or theft, or because of a change in employment, school, or residence is generally not eligible for benefits except when replacement is medically necessary due to a change in the member's health condition.

Certain devices are identified as inappropriate for home use and are not covered. Examples cited in the policy include diathermy machines, standard (non‑portable) paraffin bath units, and other items deemed unsafe or unsuitable for routine home use.

Seat lift mechanisms that operate by a spring‑release producing a sudden, catapult‑like motion that jolts the user into standing are considered investigational and are not medically necessary.

Coding: HCPCS and A-codes

Example HCPCS codes listed in policyHCPCS

G0249	Home prothrombin Time INR Monitoring Device (CoaguCheck/Protime)
E0570	Nebulizer
E0575	Nebulizer
E0585	Nebulizer
E0574	Nebulizer
E0580	Nebulizer
E0441	Oxygen (example set)
E0444	Oxygen (example set)
E0433	Portable oxygen system, regulated
E0431	Portable oxygen system, preset

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Associated A-codesHCPCS

A4463	Abdominal binder
A4620	Oxygen face mask
A4614	Flow meter

Supply A-codesHCPCS

A4210

Injector (hypodermic jet device) supplies

Ambulation aids HCPCSHCPCS

E0117	Underarm articulating spring-assisted crutch
E0118	Crutch substitute, lower leg platform
E0110	Crutches
E0114	Crutches
E0116	Crutches

Gait trainer HCPCSHCPCS

E8000	Gait trainer
E8001	Gait trainer
E8002	Gait trainer

Compression/antiembolism stocking codesHCPCS

A6561	Compression stocking - example codes listed
A6564	Compression stocking - example codes listed
A6610	Compression stocking - example codes listed
A4495	Compression stocking - example codes listed

Examples of covered HCPCS codes listed in policy textHCPCSCovered

E0441	Oxygen equipment (listed among E0441-E0444)
E0444	Oxygen equipment (listed among E0441-E0444)
E0560	Oxygen humidifier (listed)
E0550	Oxygen humidifier (listed)
E1353	Oxygen regulator (medical)
E0455	Oxygen tent
E0235	Paraffin bath unit (portable)
E0625	Patient lift
E0630	Patient lift
E0621	Patient lift

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Specific device HCPCS codes and distinctionsHCPCS

E0860	Pneumatic cervical traction unit
E0433	Portable oxygen system, regulated (adjustable flow)
E0431	Portable oxygen system, preset (non-adjustable)

Additional HCPCS codes referencedHCPCSCovered

E0615	Self-contained pacemaker equipment
E0610	Self-contained pacemaker equipment
E0160	Sitz bath
E0162	Sitz bath
L0220	Rib belt
E0627	Seat lift mechanism
E0629	Seat lift mechanism
E0642	Stander (standing frame)
E0641	Stander (standing frame)
E0638	Stander (standing frame)

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Miscellaneous DME HCPCS codesHCPCSCovered

K0743	Suction machine
E0575	Ultrasonic nebulizer
E0325	Urinal, autoclavable hospital type
E0326	Urinal, autoclavable hospital type
E0605	Vaporizer

Ventilator codesHCPCSCovered

A4611	Ventilator
A4612	Ventilator
A4613	Ventilator

Compression pressure for gradient compression dressings/stockings - inv-31

Gradient compression pressure30-50 mm Hg

IndicationPrescribed for open venous stasis ulcers and/or surgically created wounds

Product typesGradient compression nonelastic wraps or stockings and gradient compression surgical dressing stockings

Stander candidacy - inv-32

Required diagnosis typeNeuromuscular disease (e.g., cerebral palsy, spasticity, multiple sclerosis, paraparesis)

Prior therapy requirementMust have undergone physical therapy or occupational therapy

Residual function requirementMust have sufficient lower‑body residual strength to stand with assistance

Medical Necessity Details and Examples

Equipment medical necessity nodes

Ownership requirement for accessories: Reimbursement for replacement of essential accessories (hoses, tubes, mouthpieces) is made only if the individual owns the equipment.

Document ownership and medical necessity as required.

Commode coverage (summary): Commodes are covered if individual is confined to bed or room; commode chair with seat lift covered when confined to bed/room and prescribed for specified severe conditions.

See policy for definitions and codes.

Gait trainer coverage (example): Basic gait trainers are covered when ordered for individuals ≥ 2 years requiring moderate to maximum support who have reciprocal motion capability and sufficient strength and alignment to support upright weight for long periods.age >= 2 years

HCPCS E8000–E8002.

Equipment-specific medical necessity examples

Examples of equipment-specific medical necessity criteria present in this document:

Standers: Non-powered standers: neuromuscular disease causing inability to stand independently despite other assistive devices and prior PT/OT; sufficient lower-body residual strength to stand with assistance.N/A

HCPCS: E0642, E0641, E0638, E0637.

Pneumatic cervical traction: Prescribed by an eligible provider; diagnosis must be one of the listed cervical conditions; some diagnoses require documented trial of physical therapy before coverage is considered.N/A

HCPCS: E0860; see policy for full diagnosis list and PT trial requirements.

Paraffin bath unit: Successful trial of paraffin therapy ordered by a provider and expectation of long-term benefit are required for coverage.

Rental and Purchase Rules for DME

Item	Rule / Notes
General DME
{"text":"When DME is medically necessary, coverage may include rental charges (not to exceed contracted price) or purchase; repair/adjustment/replacement of parts and accessories necessary for normal and effective functioning; replacement when there is a change in the patient\'s condition; and supplies/accessories necessary for effective functioning. Repair and maintenance of rental equipment is the responsibility of the vendor/supplier. Continuing need must be verified at least every 12 months and the ordering provider should have an established ongoing relationship with the member.","status":""}

Item

Rule / Notes

General DME

{"text":"When DME is medically necessary, coverage may include rental charges (not to exceed contracted price) or purchase; repair/adjustment/replacement of parts and accessories necessary for normal and effective functioning; replacement when there is a change in the patient\'s condition; and supplies/accessories necessary for effective functioning. Repair and maintenance of rental equipment is the responsibility of the vendor/supplier. Continuing need must be verified at least every 12 months and the ordering provider should have an established ongoing relationship with the member.","status":""}

Item	Rule / Notes
Rental equipment
Repair and maintenance of rental equipment is the responsibility of the vendor/supplier; rental charges may be covered (not to exceed contracted price) unless exceptions apply for certain life‑sustaining items due to maintenance frequency.

Item	Rule / Notes
Ventilators / multifunctional ventilators
Ventilators (HCPCS A4611–A4613) are covered for appropriate indications; a second ventilator may be medically necessary when required to serve a different purpose (examples provided in policy). Multifunctional ventilators that perform additional functions (oxygen concentration, nebulization, aspiration, cough stimulation) will not be covered in the same rental month as single‑function component devices. Prior authorization and coordination of rental months may be required per member benefits.

Item

Rule / Notes

Ventilators / multifunctional ventilators

Ventilators (HCPCS A4611–A4613) are covered for appropriate indications; a second ventilator may be medically necessary when required to serve a different purpose (examples provided in policy). Multifunctional ventilators that perform additional functions (oxygen concentration, nebulization, aspiration, cough stimulation) will not be covered in the same rental month as single‑function component devices. Prior authorization and coordination of rental months may be required per member benefits.

Compression garments/stockings — subject to established frequency limits - inv-58

Replacement frequencyCompression garments/stockings are subject to established frequency limits

ApplicabilityApplies to gradient compression and antiembolism stockings listed in policy

Coverage conditionReplacements beyond established frequency limits are not covered

Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior Authorization and Verification

Prior authorization may be required for certain DME items. Verify medical necessity and obtain prior authorization where applicable before dispensing. The continuing need for DME must be documented and verified at least every 12 months. The provider ordering the DME must have an established relationship with the member and be involved in ongoing care for the condition for which the DME/orthotic is prescribed.

Confirm prior authorization rules with payer-specific administrative guidance and current policy cross-references (see updates 12/16/2024 and 06/30/2025).
Document ongoing medical necessity at least annually.
Provider placing the order must be engaged in the member's ongoing care.

Prior Authorization

Multiple Ventilators / Second Ventilator

A second ventilator may be considered medically necessary when the individual's medical needs require different devices to serve different purposes (examples: different ventilator types for different settings, or one ventilator mounted to a wheelchair and another for bed use). Multifunctional ventilators that duplicate single-function devices are not covered in the same rental month as those single-function components.

Multiple ventilators may be authorized when each serves a distinct, documented medical purpose.
Do not bill multifunctional ventilator functions concurrently with separate single-function devices for the same rental month.

Note

Prior Authorization Requirements (Administrative Updates)

Confirm any prior authorization administrative requirements and updated cross-references cited in recent administrative updates. Follow the most current policy references and payer guidance when submitting authorizations or claims.

Administrative updates: 12/16/2024 (cross-references updated) and 06/30/2025 (administrative update removed Benefit Variations Section).
Check payer portal or provider bulletins for submission instructions and required forms.

Prior Authorization

Pneumatic Cervical Traction Trial

A trial of conservative therapy (for example, physical therapy) is required for certain devices (e.g., pneumatic cervical traction) before coverage will be considered; ensure documentation of trial and response is included with the request.

Pneumatic cervical traction: coverage requires prescription and specified diagnoses; some diagnoses require documented trial of physical therapy.
Include dates, duration, and clinical response to conservative therapy in the request.

Prior Authorization

Stander Prerequisites

Standers (standing frames) require prior demonstration of need: the member must have a neuromuscular condition preventing independent standing despite PT/OT and must have sufficient lower body residual strength to stand with assistance. Providers must document prior PT/OT and functional status.

Document physical or occupational therapy trials and objective evidence of lower body strength.
Standers changed from 'deny' to medically necessary with criteria (11/13/2023); ensure requests meet the specified criteria.

Documentation Required

Accessories Documentation

Providers must document ownership of the primary DME before reimbursement for replacement accessories and provide medical necessity rationale for accessories and supplies.

Accessories (hoses, tubes, mouthpieces, etc.) are reimbursable only if the individual owns the associated equipment.
Provide proof of ownership and clinical justification for replacement accessories.

Documentation Required

Prescription and Diagnosis Documentation

Prescriptions and documentation must include the specific device ordered, the diagnosis/indication supporting medical necessity, and documentation of any required conservative therapies or prerequisites as specified in policy.

Include provider prescription, relevant ICD-10 diagnosis, and notes on prior conservative therapy when required.
Ensure the ordering provider is the treating clinician involved in ongoing care.

Denial Risk

Replacement Eligibility Risks

Replacements due to misuse, abuse, loss, theft, or changes in employment/school/residence are generally not eligible for replacement unless a medical reason is documented. Replacement is covered when there is a change in the patient's condition or when medically justified.

Replacement eligibility requires documentation of medical necessity for the replacement (e.g., change in condition).
Non-medical reasons (loss, theft, misuse, lifestyle changes) are typically not covered.

Billing Rule

Portable Oxygen System Coding/Coverage Distinction

Portable oxygen systems: preset (non-adjustable) systems (E0431) are denied except for emergency or first-aid situations; regulated adjustable flow systems (E0433) are covered when clinically indicated. Use correct HCPCS when submitting claims to avoid denials.

Preset (flow not adjustable) E0431 — Deny except for emergency/first-aid.
Regulated (adjustable flow) E0433 — Covered when criteria are met.

Note

Standards Changed from 'Deny' to Medically Necessary with Criteria

Standards for certain items (e.g., standers) were changed from 'deny' to medically necessary with defined criteria (11/13/2023 minor review). Requests failing to meet the updated medical necessity criteria may be denied.

Review the 11/13/2023 policy change when evaluating stander requests.
Ensure all criteria are met and documented to avoid denial.

Documentation Requirements

Documentation Required

Annual verification and provider involvement required for ongoing coverage

Verify continuing need at least every 12 months; the ordering provider must have an established relationship and remain involved in ongoing care — this applies to supplies billed for the equipment as well.

Document verification of continuing need in the medical record at least annually.
Ensure supplies billed each cycle reference the established provider involvement as required.

Billing Rule

Proof of ownership required to reimburse accessories

Reimbursement for essential accessories is only made if the individual owns the primary equipment and the accessory is medically necessary for normal and effective functioning.

Document ownership of the equipment and the medical purpose of each accessory when submitting claims.
Accessories without proof of ownership are not eligible for replacement reimbursement.

Documentation Required

Document diagnosis, indication, and prior conservative therapy when prescribing

The prescribing provider must document the diagnosis, the indication for the device, and any required prior conservative therapy (for example, a trial of physical therapy where specified) to support medical necessity for device coverage.

Include the specific diagnosis from the policy's allowed list when ordering devices like pneumatic cervical traction (E0860).
Attach documentation of prior conservative therapy when the policy requires it for the diagnosis.

Note

Follow updated policy text and cross-references for documentation requirements

Refer to the current policy text and cross-references for exact documentation requirements and administrative guidance; administrative updates occurred 12/16/2024 and 06/30/2025 that modified cross-references and removed Benefit Variations.

Use the latest policy version when preparing supporting documentation for authorizations and claims.
Administrative updates in 2024–2025 may affect where documentation rules are referenced.

Items and Situations Not Covered

The policy lists multiple categories of items that are not covered because they are comfort/convenience items, environmental control equipment, or otherwise not primarily medical in nature. Examples include lounge/power beds, hot/ice packs, overbed tables, spare oxygen tanks, air cleaners, central or room humidifiers, portable room heaters, and similar environmental control devices.

Equipment deemed inappropriate for home use (for example, standard diathermy machines and non‑portable paraffin bath units) and non‑medical items such as certain strollers and exercise equipment are also excluded from coverage.

When considering oxygen systems, the policy distinguishes between regulated (adjustable flow) portable oxygen systems (covered) and preset (non‑adjustable, e.g., E0431) portable systems, which are denied except for emergency or first‑aid use.

Replacement items resulting from loss or theft, or replacement necessitated by misuse or abuse of equipment, are generally not eligible for coverage. Similarly, duplicate equipment provided for convenience (for travel or an additional residence) is not covered unless there is a demonstrable change in the member's medical condition that makes the additional item medically necessary.

Patient lifts that would require home modification are not covered. Preset (non‑adjustable) portable oxygen systems are denied for non‑emergency/first‑aid use (the policy cites E0431 as denied), while regulated (adjustable flow) portable oxygen systems (E0433) are covered where clinically indicated. Multifunctional ventilators that combine functions (e.g., oxygen concentration, nebulization, aspiration) will not be covered in the same rental month as other single‑function component devices.

Policy history notes indicate prior language and standards have been revised over time; some earlier denial language was changed in later reviews. The document notes administrative and minor reviews but does not present additional explicit not‑covered items within this segment.

Background

Durable Medical Equipment (DME) is equipment that is primarily and customarily used to serve a medical purpose, is not generally useful in the absence of illness or injury, is reusable and appropriate for use in the home, and is ordered by an appropriate licensed provider. DME is intended to provide a therapeutic benefit and support treatment, and coverage is determined when device‑specific medical necessity criteria and documentation requirements are met.

Definitions

Durable Medical Equipment (DME) definition - inv-48

Primary useItems primarily and customarily used to serve a medical purpose

Home suitabilityAppropriate for use in the home

Durability and orderingReusable and ordered by a licensed provider within scope of practice

Not useful when healthyNot useful in the absence of illness or injury

Room confined - inv-49

DefinitionCondition such that leaving the room is medically contraindicated

EquivalencyLack of home toilet facilities may be equated to room confinement

ContextUsed to determine coverage for commodes and bedpans

Durable Medical Equipment (alternate entry) - inv-50

Canonical definitionItems primarily and customarily used to serve a medical purpose; not useful absent illness or injury; ordered by a physician; appropriate for home use; reusable and able to withstand repeated use

SynonymAlso referred to as Home Medical Equipment (HME)

ExamplesIncludes hospital beds, wheelchairs, canes, crutches, walkers, ventilators, oxygen, monitors, lifts, commodes, nebulizers, pressure mattresses

Back-up (secondary) DME - inv-51

DefinitionBack-up or secondary DME: an identical or similar piece of equipment to one already in use that could meet the same medical needs of the patient

PurposeIntended to serve as a substitute to meet the same medical needs

Coverage implicationDuplicate equipment for convenience (additional residences) generally not covered unless medically necessary due to change in health condition

Replacement and Frequency Limits

Compression garments/stockings replacement — subject to established frequency limits - inv-58

Replacement ruleCompression garments and stockings are covered subject to established frequency limits

ConsequenceReplacements that exceed established frequency limits are not covered

IncludesGradient compression and antiembolism (TED) stockings listed in policy

Policy Revision History

2025-06-30administrative_updateLatest

Administrative update removing the Benefit Variations section and updating the disclaimer.

2025-02-15major_review

Major review completed with no changes to the clinical policy statement; policy updated (02/15/2025 entry shown in source as 02/12/25/2025 but brief lists 02/15/2024 - retained source-backed 02/12/2025).

2024-12-16consensus_review

Consensus review with no changes to the clinical policy statement; updated cross-references.

2024-02-15minor_review

Minor review removed language regarding blood pressure cuffs.

2023-11-13minor_review

Minor review changed standers from 'deny' to medically necessary with defined criteria.

2021-08-12minor_review

Minor review added additional criteria for DME supplies and updated references.

2020-06-22consensus_review

Consensus review; policy statement unchanged; product/benefit variations and disclaimer updated and references/tables reviewed.

Policy Summary

PayerCapital Bluecross

PolicyDurable Medical Equipment and Supplies

Policy CodePolicy MP 6.026

Change TypeNo material change

Effective DateSep 1, 2025

Next Review DateN/A

Key ActionVerify medical necessity and document continuing need at least every 12 months and ensure the prescribing provider is involved in ongoing care.

SourceLink

On This Page

HCPCS: E8000–E8002.