Durable Medical Equipment and Supplies
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Defines Capital Bluecross coverage rules for durable medical equipment and related supplies, including definitions, item-level medical necessity criteria, rental/purchase and replacement rules, examples of covered and not-covered items, and coding references affecting providers and members.
No material clinical or coverage changes in this revision.
Coverage Criteria for DME
Coverage criteria
Covered when ALL of the following are met:
Item-specific coverage criteria (partial)
Coverage varies by device and is subject to medical necessity criteria; specific examples and conditions include:
Coding and HCPCS/CPT References
| E0433 | Portable oxygen system, regulated (adjustable flow rate) |
| E0431 | Portable oxygen system, preset (not adjustable) |
| E0445 | Pulse oximeter |
| A4606 | Pulse oximeter replacement probe |
| E0606 | Postural drainage board |
| L0220 | Rib belt |
| E0615 | Self-contained pacemaker accessory |
| E0610 | Self-contained pacemaker accessory |
| E0160 | Perineal protective device |
| S8100 | Spacer device |
Provider Responsibilities and Notes
Provider relationship and ongoing-care requirement
The provider requesting or ordering the DME must be a provider with an established relationship with the member and actively involved in the ongoing care of the member and the condition for which the DME/orthotic is prescribed.
Coding and coverage note
The coding list is provided for reference only; identification of a code does not denote coverage — actual coverage is determined by the member's benefit information and whether the item meets medical necessity.
- Code lists are illustrative and may not be all-inclusive; codes are subject to change.
- Coverage decisions are based on member benefit terms and documented medical necessity.
Follow referenced specific medical policies
When a specific medical policy exists for an item or service, the provider must follow that specific policy's medical necessity criteria and refer to the named policy for applicable requirements.
- Examples: refer to MP 6.001 for hospital and specialized beds, MP 6.032 for speech-generating devices, MP 2.045 for CPAP, etc.
Definitions
Medical Necessity Rules
Equipment-specific medical necessity
Item-specific medical necessity notes and examples:
Selected medical necessity rules
Selected device-specific requirements and operational rules:
Rental and Purchase Rules
| Topic | Rule / Notes |
|---|---|
| Rental vs Purchase | |
| When DME is medically necessary, coverage may include rental charges (not to exceed the contracted price except for certain life‑sustaining items) or purchase of the item; repair, adjustment, or replacement of parts and accessories necessary for normal and effective functioning is covered. | |
| Replacement | |
| Replacement of an item is covered when there is a change in the patient’s condition. No benefits are provided for replacement due to misuse/abuse, lost/stolen items except in circumstances of risk of disability or death or other medically necessary reasons. | |
| Supplies and Accessories | |
| Supplies and accessories necessary for effective functioning of the DME may be covered based on actual member usage; amounts should be documented each billing cycle. | |
| Vendor/Supplier Responsibility | |
| Repair and maintenance of rental equipment is the responsibility of the vendor/supplier. | |
| Provider Relationship & Documentation | |
| The provider requesting/ordering the DME should have an established relationship with the member and be involved in ongoing care; providers must document medical necessity and ongoing need (verified at least every 12 months). |
| Billing Topic | Billing Rule |
|---|---|
| Responsibility for maintenance | |
| Repair and maintenance of rental equipment is the responsibility of the vendor/supplier. | |
| Reimbursement for accessories | |
| Reimbursement may be made for replacement of essential accessories (e.g., hoses, tubes, mouthpieces) for medically necessary DME when the individual owns the equipment. | |
| Documentation of usage | |
| Supplies and accessories coverage is based on actual member usage and should be documented each billing cycle. | |
| Limitations | |
| Rental charges should not exceed contracted price except for certain life‑sustaining items due to maintenance frequency. |
| Ventilator / Multifunction Device Topic | Rule / Billing Specifics |
|---|---|
| Multiple ventilators for different uses | |
| Coverage may be medically necessary for an individual to have more than one ventilator when each serves a different purpose (e.g., one ventilator for part of the day and a different type for the remainder, or a ventilator mounted on a wheelchair plus another for bed use). | |
| Multifunction ventilator billing restriction | |
| Multifunction ventilators (devices that perform additional functions such as oxygen concentration, drug nebulization, aspiration, and cough stimulation) will not be covered in the same rental month as other single‑function devices which are components of the multifunction device. |
Replacement, Repairs and Accessories
Documentation Requirements
Document ongoing care and member usage each billing cycle
Documentation must show the provider's ongoing involvement in the member's care and actual member usage of supplies/equipment; actual member usage should be documented each billing cycle.
- Verify continuing need for DME at least every 12 months.
- Document actual member usage each billing cycle when supplies are provided.
Document medical necessity and adhere to referenced policy criteria
Providers must document medical necessity for DME and follow any criteria in referenced specific policies when those policies apply.
Not Covered Items
The following items and categories are not covered under this DME policy because they are considered comfort/convenience items, environmental control equipment, consumable or non‑medical goods, structural modifications, duplicate equipment, or otherwise inappropriate for the DME benefit.
Comfort and convenience items that are excluded include, but are not limited to: lounge (power or manual) beds, carafes, emesis basins, enuresis monitors, hot packs, ice packs, massage pillows, thermocyclopads, overbed tables, rolling chairs, standing tables, and spare tanks of oxygen.
Equipment used for environmental control is not covered, including air cleaners, air conditioning or central HVAC systems, dehumidifiers, room or central humidifiers, and portable room heaters.
Items deemed inappropriate for home use are excluded from coverage; examples include standard or pulse‑wave diathermy machines, esophageal dilators, mobile monomatic sanitation systems, standard paraffin bath units, tractomatic intermittent traction units, and hospital‑grade breast pumps.
Consumable medical supplies that are disposable or expendable are not covered under the DME benefit (examples: disposable sheets, fabric supports, surgical face masks, surgical stockings), nor are goods that are not primarily medical in nature (examples: positioning pillows, seat tilt devices, strollers, certain over‑toilet commodes, bed lifters, exercise equipment).
Also excluded are modifications to structures or vehicles (for example, wheelchair ramps) and duplicate equipment for additional residences or travel unless otherwise specified and medically necessary in exceptional circumstances.
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