ModifiedDHAPolicy 3.0

Durable Equipment (DE) Basic Program

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This policy governs the Durable Equipment Basic Program, including coverage criteria, medical necessity, equipment rules, documentation, coding, repairs, replacements, upgrades, and mobile medical applications.

Policy Summary

PayerDHA

PolicyDurable Equipment (DE) Basic Program

Policy CodePolicy 3.0

Change TypeModified

Effective DateSep 1, 2005

Next Review DateN/A

Key ActionObtain an adequate prescription and supporting medical-necessity documentation from an authorized individual professional provider.

SourceLink

POLICY UPDATE CHANGES

Mobile medical applications must meet TRICARE DME requirements, be proven safe and effective by DHA, be condition-specific and medically necessary, be prescribed by an authorized provider, be FDA approved or cleared, and comply with HIPAA requirements.

Coverage eligibility for mobile medical applications is limited to applications listed by TRICARE, and currently no mobile medical applications meet TRICARE coverage criteria.

Smartphones, tablets, personal computers, smart watches, and other platforms that do not meet TRICARE's DE or DME definition are excluded from coverage.

Mobile medical applications must be condition-specific, medical in nature, medically or psychologically necessary, prescribed by a TRICARE-authorized provider, FDA approved or cleared, and compliant with HIPAA to qualify for coverage.

Platforms that do not meet TRICARE's definition of DE or DME, including smartphones, tablets, personal computers, and smart watches, are excluded from coverage.

Separate reimbursement for an MMA and its associated sensor or connected medical device is restricted unless each component independently qualifies and the MMA provides a medically necessary service independent of the device.

Beds designed to prevent falls or protect individuals from entanglement or entrapment, and all accompanying accessories, are excluded when the beds are nonmedical comfort or convenience items.

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ModifiedDHAPolicy 3.0

Durable Equipment (DE) Basic Program

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Sign up for DHA Policy 3.0 alerts

Get alerted when Policy 3.0 changes without checking for updates manually.

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Policy Summary

PayerDHA

PolicyDurable Equipment (DE) Basic Program

Policy CodePolicy 3.0

Change TypeModified

Effective DateSep 1, 2005

Next Review DateN/A

Key ActionObtain an adequate prescription and supporting medical-necessity documentation from an authorized individual professional provider.

SourceLink

POLICY UPDATE CHANGES

Coverage eligibility for mobile medical applications is limited to applications listed by TRICARE, and currently no mobile medical applications meet TRICARE coverage criteria.

Smartphones, tablets, personal computers, smart watches, and other platforms that do not meet TRICARE's DE or DME definition are excluded from coverage.

Platforms that do not meet TRICARE's definition of DE or DME, including smartphones, tablets, personal computers, and smart watches, are excluded from coverage.

Beds designed to prevent falls or protect individuals from entanglement or entrapment, and all accompanying accessories, are excluded when the beds are nonmedical comfort or convenience items.

Basic ProgramProgram scope

4Covered equipment categories

Basic modelStandard coverage level

3 monthsInitial MMA evaluation

0Currently eligible MMAs

No MMAsMMA coverage status

Coverage Criteria

General durable-equipment coverage

DE is cost-shared when all applicable requirements are met.

Basic DE eligibility: The item is medically necessary and appropriate; is ordered by a TRICARE-authorized individual professional provider for the specific use of the beneficiary; meets the DE definition; is adequately documented; provides the medically appropriate level of performance and quality; is prescribed for an FDA-approved use; and is not otherwise excluded by regulation or policy.

Only the base or basic model, or a more cost-effective alternative, is generally covered.

Covered equipment

Covered when medically necessary.

Covered equipment categories: The equipment is a hospital bed, iron lung, durable medical equipment, wheelchair, or a cardiorespiratory monitor under the conditions specified in Section 2.2.

Hospital-bed accessories are also covered when medically necessary.

Wheelchairs and vehicle lifts

Wheelchair-related equipment is covered when all applicable mobility requirements are met.

Wheelchair and lift coverage: The wheelchair meets the DE definition and provides medically appropriate basic mobility; an electric wheelchair or TRICARE-approved alternative may replace a manual wheelchair for basic mobility; and a vehicle lift is necessary to transport an otherwise authorized wheelchair or approved alternative, is a basic temporary transferable lift, and transports the wheelchair itself.

Benefits are not extended for both an electric cart-type vehicle and an electric wheelchair during the same period. Only allowable basic lift and installation charges are covered.

Customization and wheelchair modification

Customization or modification is covered when necessary for therapeutic benefit, serviceability, proper function, basic mobility, or proper use.

Customization and modification: DME customization is essential for achieving therapeutic benefit, making the equipment serviceable, or assuring proper functioning; or a wheelchair modification accommodates a particular physiological or medical need and is necessary to provide basic mobility and allow proper use of the wheelchair.

Substantial or uniquely built wheelchair modifications are covered only through a lump-sum purchase or rental-purchase agreement resulting in beneficiary ownership.

Repairs and replacements

Repair or replacement is covered when the applicable condition is met.

Repair and replacement: Repair of beneficiary-owned DE is necessary to restore function because of reasonable wear and usage, the manufacturer's warranty has expired, and the repair cost is less than the replacement cost; or replacement is necessary because the equipment is lost or stolen without other insurance, is nonfunctional because of normal wear or accidental damage, is no longer appropriate because of a change in the beneficiary's condition, or has been declared adulterated by the FDA.Repair cost < replacement cost for covered repair; replacement cost < repair cost for replacement review.

Replacement requires documentation that the current item is no longer usable or repairable and a new order or prescription from an authorized provider explaining medical need.

Mobile medical applications

An MMA is eligible only when all criteria are met and TRICARE lists it as eligible.

Mobile medical application eligibility: The MMA meets TRICARE's DME definition and all DME coverage requirements; is determined by DHA to be proven safe and effective under the applicable evidence hierarchy; is condition-specific, medical in nature, and medically or psychologically necessary; is prescribed by a TRICARE-authorized provider; is FDA approved or cleared; complies with HIPAA; and is listed as eligible for coverage by TRICARE.Monthly subscription: medical-necessity evaluation after 3 months and every 12 months thereafter; annual subscription: annual evaluation.

Currently, no MMAs meet TRICARE coverage criteria.

Mobile medical application criteria

An MMA must meet all of the following requirements to qualify for coverage.

MMA eligibility: The MMA is condition-specific, medical in nature, medically or psychologically necessary, prescribed by a TRICARE-authorized provider acting within the scope of the provider's license, approved or cleared by the FDA, and compliant with HIPAA requirements.

Subscription-based MMAs require annual prescriptions.

MMA and sensor or connected-device coverage

Both components must satisfy the applicable coverage requirements when an MMA requires a sensor or connected medical device to function as one unit.

MMA and associated device: The MMA and the sensor or connected medical device each meet the applicable TRICARE coverage requirements when they function as one unit; an eligible MMA does not establish coverage for a nonqualifying associated device or platform.

Separate reimbursement is permitted only when the MMA provides a medically necessary service independent of the associated device and separate reimbursement is applied to all payers, including out-of-pocket purchasers.

Medically necessary equipment upgrades

A medically necessary upgrade is covered only when the underlying DE item meets the DE benefit requirement.

Medically necessary upgrade: The upgraded DE item otherwise meets the DE benefit requirement, and the prescription specifically states the medical reason the upgrade is necessary. For a wheelchair, the upgrade must be required for the beneficiary to maintain basic mobility.

Without supporting documentation, reimbursement is limited to the allowed amount for the base model, with the beneficiary responsible for the difference.

Beneficiary-preferred upgrades

A beneficiary-preferred upgrade may be obtained when the underlying equipment meets benefit requirements.

Beneficiary-preferred upgrade: The upgraded item otherwise meets the DE benefit requirements and is within the range of services appropriate for the beneficiary's medical condition.

The beneficiary is solely responsible for the cost above the standard equipment amount. A standard manual wheelchair may be upgraded to a power wheelchair when there is no medical objection, but a walker may not be upgraded to a wheelchair under this provision.

Excluded items include communication devices other than those specifically allowed by policy, eyeglasses, and devices intended for exercise, relaxation, comfort, or convenience. Items otherwise excluded by regulation or policy are also not covered.

Vehicle conversions are excluded, including raising the vehicle roof, widening doors, and installing permanent or non-transferable attachments. Purchases or conversions of personal vehicles for a wheelchair-bound beneficiary are outside the scope of TRICARE medical benefits.

Vehicle lifts beyond the basic or standard model are excluded. If a beneficiary selects a luxury or deluxe lift, the beneficiary is responsible for costs above the allowable amount for the basic lift and authorized installation.

Smartphones, electronic tablets, personal computers, smart watches, and associated data or voice plans are not covered when the platform does not meet TRICARE's DE or DME definition. Sensors and connected medical devices must independently satisfy applicable DME requirements; noncovered devices are excluded.

An MMA that only visualizes data from a covered sensor or connected medical device is not separately reimbursable because it does not provide an independent medically necessary service. Separate reimbursement for an MMA and associated device is allowed only when the MMA provides an independent medically necessary service and separate charges are applied to all payers, including out-of-pocket purchasers.

MMAs are excluded from the basic benefit unless TRICARE determines that the MMA meets every criterion in paragraph 3.12.2 and lists it as eligible. No MMAs currently meet TRICARE coverage criteria.

DE is excluded when the beneficiary is a patient in a facility that ordinarily provides the same type of DME item to patients at no additional charge in the usual course of providing its services.

DE that is available to the beneficiary from a Military Medical Treatment Facility is excluded from coverage.

Lost or stolen DE, equipment still under warranty, and DE damaged while used in a manner inconsistent with its common use are excluded. Loss or theft may be considered under the applicable replacement provision in paragraph 3.10, and other replacement requirements must be met.

Luxury, deluxe, immaterial, or non-essential features that increase the cost of an item compared with a similar item are excluded. Coverage is generally limited to the basic model or a more cost-effective alternative.

Items intended primarily for exercise, relaxation, comfort, sporting, recreation, spas, whirlpools, hot tubs, swimming pools, health-club memberships, or similar purposes are excluded from DE coverage.

Repairs to deluxe, luxury, or immaterial features of DE are excluded, except as provided under paragraph 3.9.

Repairs to DE damaged while the equipment was used in a manner inconsistent with its common use are excluded.

Maintenance agreements are excluded from coverage.

Routine periodic servicing—such as testing, cleaning, regulating, or checking—is excluded when the manufacturer does not require the service to be performed by an authorized technician.

Duplicate otherwise allowable DE used solely as a backup to currently owned or rented equipment is excluded, except as provided under paragraph 3.11.

Items that do not withstand repeated use are not durable equipment and are excluded. Examples include incontinent pads, diapers, and ace bandages.

Nonmedical equipment is excluded, including humidifiers, electric air cleaners, exercycles, safety grab bars, and training equipment.

Beds that are not medical in nature and are used for comfort or convenience are excluded. Examples include power or manual lounge beds, sleep-number beds, and ordinary beds typically sold as furniture. Beds designed to prevent falls or protect against entanglement or entrapment, such as Beds by George Haven and Cubby beds, and all accompanying accessories are also excluded when they are nonmedical comfort or convenience items.

Coverage is generally limited to the basic model or a more cost-effective alternative that provides the medically appropriate level of performance and quality. Excess luxury, deluxe, immaterial, or non-essential features that increase cost compared with a similar item are not authorized unless a policy exception applies.

A vehicle lift is not medically necessary when it transports the beneficiary rather than the wheelchair or is used to transport the beneficiary to or from medical appointments. A lift may be authorized solely to transport the wheelchair so the traveling beneficiary has basic mobility at the destination.

An MMA used for general health or wellness rather than treatment of a specific health condition is not medically necessary. An MMA that lacks medical or psychological necessity also does not qualify for coverage.

Comfort, convenience, luxury, deluxe, immaterial, and non-essential features are not medically necessary when they exceed what is needed for treatment or basic mobility, or increase the cost relative to comparable equipment without those features.

HCPCS Coding

HCPCS CodesHCPCS

E0100-E1900	Level II Codes
E0250-E0270	Level II Codes
E0290-E0297	Level II Codes
E0301-E0304	Level II Codes
K0001-K0547	Level II Codes
K0553	Level II Codes
K0554	Level II Codes

Provider Actions and Denial Risks

Documentation Required

Order and Medical-Necessity Documentation

Before cost-sharing durable equipment (DE), obtain an order or prescription from a TRICARE-authorized individual professional provider acting within the scope of the provider’s license or certification. Document the beneficiary-specific medical need, medically appropriate level of performance and quality, intended use, and other adequate documentation required by policy.

Authorized ordering professionals include physicians, dentists, authorized allied health professionals, DPMs, ODs, PAs, specified advanced practice nurses, CRNAs, PTs, and OTs.
The item must be medically necessary and appropriate for the beneficiary’s specific use.

Documentation Required

Document Extraordinary FDA-Approved Use

When the prescribed use of an item appears extraordinary, obtain a signed manufacturer statement confirming that the specific medical device is FDA approved for that use.

The signed manufacturer statement is adequate evidence of FDA approval for the extraordinary use.

Required Documentation

Documentation Required

Obtain an adequate prescription and medical-necessity record

Obtain an adequate prescription from a TRICARE-authorized individual professional provider acting within the scope of the provider’s license or certification. The order must identify the beneficiary-specific use and be supported by documentation of medical necessity, appropriate performance and quality, and compliance with the durable-equipment definition.

Documentation Required

Document FDA approval for extraordinary use

When the prescribed use appears extraordinary, obtain a signed manufacturer statement confirming that the specific medical device is FDA approved for that use.

Documentation Required

Document the qualifying replacement reason

For replacement, document loss, theft, damage, normal wear, a change in the beneficiary’s condition, FDA adulteration, or another qualifying reason, and explain why the current item is no longer usable or repairable. A new order or prescription explaining medical need is required.

Program Background

This policy covers equipment needed to provide medically appropriate treatment, basic mobility, therapeutic benefit, or essential in-home life support. Coverage generally supports the base or basic model and may include certain repairs, replacements, customizations, and medically necessary modifications when they restore function or accommodate the beneficiary's condition.

Key Definitions

Durable equipment (DE)

DefinitionDurable equipment (DE) is defined in 32 CFR 199.2.

Coverage contextDE is a medically necessary and appropriate item ordered by a TRICARE-authorized individual professional provider for the beneficiary's specific use.

Program statusDE that complies with the applicable definition and coverage criteria is cost-shared.

Durable medical equipment (DME)

DefinitionDurable medical equipment (DME) is durable equipment that is medically appropriate as defined in 32 CFR 199.2.

Relationship to DEDME is a category of durable equipment under the policy.

Medical Necessity Framework

Core DME medical necessity

Equipment must meet all applicable medical-necessity and documentation requirements.

Core DME necessity: The equipment is medically necessary and appropriate for the beneficiary; ordered by an authorized provider for the beneficiary-specific use; adequately documented; appropriate in performance and quality for the beneficiary's medical condition; prescribed for a use consistent with FDA-approved labeling; and not otherwise excluded by regulation or policy.

Coverage is generally limited to the basic model or a cost-effective alternative.

Mobility equipment

Mobility equipment must be necessary to provide basic mobility and allow proper use.

Mobility equipment: The wheelchair or approved alternative meets the DE definition and is medically appropriate for basic mobility; any vehicle lift is necessary to transport the wheelchair, is basic and transferable, and includes only allowable installation; and any wheelchair modification is medically necessary to accommodate the beneficiary's physiological or medical need and allow proper use.

Rental and Purchase Rules

Equipment	Rental	Purchase	Capped rental
Covered durable equipment	Available when rental is the most advantageous option based on the anticipated duration of medically necessary need and current pricing.	Available as a lump-sum purchase when that option is most advantageous to the Government.	Lease-purchase option considered in the cost comparison; the Government compares the total monthly rental, lease-purchase, and lump-sum purchase prices, including the applicable time value of money.

Equipment	Purchase	Capped rental
Substantially modified or uniquely built wheelchair	Covered only through a lump-sum purchase that results in beneficiary ownership.	Covered through a rental-purchase agreement that results in beneficiary ownership.

Not Covered

Not covered: luxury, deluxe, immaterial, or non-essential equipment features; communication devices not otherwise allowed by policy; and eyeglasses.

Policy Summary

PayerDHA

PolicyDurable Equipment (DE) Basic Program

Policy CodePolicy 3.0

Change TypeModified

Effective DateSep 1, 2005

Next Review DateN/A

Key ActionObtain an adequate prescription and supporting medical-necessity documentation from an authorized individual professional provider.

SourceLink

On This Page

Documentation Required

Support DME Customization

For beneficiary-owned DME customization, document why the permanent customization or accessory is essential for the beneficiary’s therapeutic benefit, equipment serviceability, or proper functioning. Coverage is determined by the Director or designee.

Customization must be designed permanently to preclude use by another individual.
Support the specific functional or therapeutic need requiring customization.

Documentation Required

Document Specialized Wheelchair Construction

For substantial wheelchair modifications or a uniquely constructed wheelchair, document the beneficiary’s special physiological or medical needs and why the modification or unique construction is medically necessary for basic mobility and proper use. Covered arrangements must result in beneficiary ownership through lump-sum purchase or rental-purchase.

Slight or small modifications may be covered when needed to accommodate a particular physiological or medical need.
Substantial modification or unique construction requires documentation of the special need and medical necessity.

Documentation Required

Document Replacement Eligibility

For replacement of beneficiary-owned DE, document the qualifying reason the existing item is no longer usable or repairable and confirm that replacement is more appropriate financially than repair. A new order or prescription from a TRICARE-authorized individual professional provider must explain the medical need.

Qualifying grounds include loss or theft not covered by other insurance, normal wear, accidental damage, a change in the beneficiary’s condition, or FDA adulteration.
Document why the current item is no longer usable or repairable and that replacement cost is less than repair cost.
For rented equipment lost or stolen, the supplier must use modifier RA; rental payment for the original item is the supplier’s contractual responsibility.

Documentation Required

Document MMA Eligibility

Before billing a mobile medical application (MMA), document that it meets TRICARE’s DME definition and coverage requirements, is condition-specific and medically or psychologically necessary, is prescribed by an authorized provider, is FDA approved or cleared, and complies with HIPAA. The MMA must also be proven safe and effective by DHA and listed as eligible for coverage.

Document DME status, reliable-evidence approval by DHA, condition-specific medical use, provider prescription, FDA status, and HIPAA compliance.
Do not treat general health, wellness, or overall lifestyle-support applications as eligible MMAs.
For subscription-based MMAs, retain the required prescription and support the contractor’s recurring medical-necessity evaluations.

Unsupported block type: documentation

Documentation Required

State the Medical Reason for an Upgrade

For an upgraded DE item, ensure the prescription specifically states the medical reason the upgrade is necessary. For wheelchair upgrades, document that the upgrade is required to maintain basic mobility.

Examples include inability to lift a standard walker because of insufficient physical strength or balance.
The upgraded item must otherwise meet DE benefit requirements and be appropriate for the beneficiary’s medical condition.

Billing Rule

Obtain Written Upgrade Liability Agreement

Before collecting charges above the Government’s allowed amount for standard equipment, give the beneficiary written notice that the upgrade has been or may be denied and obtain the beneficiary’s written agreement to pay the difference. Without both notice and agreement, applicable hold-harmless rules may apply.

The agreement must address the difference between charges for the upgraded item and charges for the standard item.
The beneficiary is also responsible for repairs to upgraded items or features.

Denial Risk

Denial Risk: Necessity, Authorization, or Documentation Failure

Expect denial when the item is not medically necessary or appropriate, is not ordered by an authorized provider, is outside the provider’s scope of practice, or lacks the required order, prescription, medical-necessity explanation, or supporting documentation.

The item must be for the beneficiary’s specific use and provide the medically appropriate level of performance and quality.
Replacement claims require a new authorized-provider order or prescription explaining medical need.

Denial Risk

Denial Risk: Nonbasic or Excluded Equipment

Do not bill luxury, deluxe, immaterial, non-essential, comfort, convenience, or otherwise excluded equipment as covered DE when those features increase cost without being medically necessary. Coverage is limited to the basic model or a more cost-effective alternative unless a specific policy exception applies.

Excluded categories include communication devices outside the permitted benefit, eyeglasses, exercise or relaxation devices, and comfort or convenience items.
The equipment must also comply with FDA-approved labeling and must not otherwise be excluded by regulation or policy.

Denial Risk

Denial Risk: Ineligible Lift or Wheelchair Modification

A lift is not covered when it is nonbasic, permanent, non-transferable, intended to transport the beneficiary rather than the authorized wheelchair, or part of an excluded vehicle conversion. Wheelchair modifications are not covered unless medically appropriate and necessary for basic mobility and proper use; substantial or uniquely constructed chairs require the specified ownership arrangement and documentation.

Covered lifts are limited to basic or standard models and authorized installation labor.
Excluded conversions include raising a roof, widening a door, or permanent attachments that cannot transfer to another vehicle.
A luxury or deluxe lift beyond the basic model is excluded from the allowable amount; the beneficiary may be responsible for the difference only under applicable liability-notice requirements.

Denial Risk

Denial Risk: Repair or Replacement Inadequacy

Do not bill repairs when they are unnecessary, covered by the manufacturer’s warranty, or cost as much as or more than replacement. Do not approve replacement without documentation that the existing item is no longer usable or repairable and that replacement is less costly than repair.

Repairs are limited to beneficiary-owned DE made functional because of reasonable wear and usage after the warranty has expired.
Replacement grounds include loss, theft without other insurance coverage, normal wear, accidental damage, change in condition, or FDA adulteration.
A temporary replacement may be covered during a reasonable repair period; lost or stolen rented equipment does not support continued rental payment for the original item.

Denial Risk

Denial Risk: MMA Eligibility Failure

Deny an MMA when it fails any required eligibility condition, including DME status, DHA evidence requirements, condition-specific medical necessity, authorized prescription, FDA approval or clearance, or HIPAA compliance. General wellness applications and applications not listed as eligible are not covered.

An MMA must treat a specific health condition and be medical in nature, rather than support overall health or wellness.
Sensors and connected medical devices must separately satisfy applicable DME requirements.
A subscription MMA remains subject to recurring medical-necessity evaluation.

Denial Risk

MMA Fails Coverage Criteria

MMAs are excluded from the basic benefit unless TRICARE determines that all criteria in paragraph 3.12.2 are met and lists the MMA as eligible in paragraph 3.12.5. Currently, no MMA meets TRICARE coverage criteria.

All eligibility criteria must be satisfied; partial compliance is insufficient.
Treat unlisted MMAs as excluded from coverage.

Denial Risk

Denial Risk: Noncovered Platform or Device

Do not separately reimburse noncovered platforms, sensors, or connected devices. Smartphones, tablets, personal computers, smart watches, and associated data or voice plans are excluded when they do not meet the DE or DME definition.

An MMA that only visualizes data from a covered sensor or connected device is not eligible for coverage.
If a covered MMA requires a sensor or connected device to function, both components must be eligible for reimbursement.
Separate reimbursement for an MMA and associated equipment is permitted only when the MMA provides an independent medically necessary service and separate charges are applied consistently to all payers, including self-paying patients.

Denial Risk

Upgrade Lacks Medical-Necessity Documentation

If an upgrade is deluxe, luxury, or immaterial and the prescription does not document why the feature is medically necessary, apply the TRICARE allowed amount for the base model. The beneficiary is responsible for the difference between the base-model allowance and the provider’s billed charges.

A wheelchair upgrade must be required to maintain basic mobility.
A beneficiary may choose an otherwise appropriate upgrade, but the Government does not pay beyond the standard-equipment amount without documented medical necessity.

Denial Risk

Missing Upgrade Liability Notice

Do not collect the excess cost of an upgraded item unless the beneficiary first receives written notice that the upgrade has been or may be denied and signs a written agreement accepting liability for the difference from standard-equipment charges.

Failure to provide written notice and obtain written agreement may trigger hold-harmless protections for network providers and applicable restrictions for non-network providers.
The beneficiary remains liable for repairs to the upgraded item or features when the liability requirements are satisfied.

Documentation Required

Document medical necessity for an upgraded item

The prescription must specifically identify why the upgraded equipment or feature is medically necessary and why the standard equipment is inadequate. A wheelchair upgrade must be required for the beneficiary to maintain basic mobility.

Billing Rule

Document the beneficiary’s upgrade agreement

Before collecting charges above the standard equipment amount, give the beneficiary written notice that the upgrade has been or may be denied and obtain written agreement to financial liability for the difference between the upgraded and standard equipment charges.

The equipment must be medically appropriate to qualify as DME.

Mobile medical application (MMA)

DefinitionA mobile medical application (MMA), also known as an mHealth app, software-as-a-medical device, or digital therapeutic, operates using a mobile platform.

Supported platformsSupported platforms include smartphones, tablets, smart watches, and other mobile platforms.

PurposeAn MMA is designed to benefit an individual's health or wellness.

Medical-device functionAn MMA either meets the definition of a medical device, serves as an accessory to a medical device, or transforms a mobile platform into a medical device.

Duplicate equipment

DefinitionDuplicate equipment is an item that meets the definition of durable equipment and serves the same purpose as another item.

Prior coverageThe other item must have been previously cost-shared by the TRICARE program.

Comparison standardEquipment is evaluated according to whether it serves the same purpose as the previously cost-shared equipment.

Sensor

DefinitionA sensor is technology designed to take biometric readings from patients and upload that information to a platform for use with a mobile medical application.

Medical examplesExamples include blood-pressure monitors, thermometers, electrocardiograms, and blood glucometers.

Nonmedical exampleFitness trackers may also qualify as sensors under the policy's definition.

Platform connectionThe biometric information is uploaded to a platform for use with an MMA.

Connected medical device

DefinitionA connected medical device integrates with an mHealth application.

Monitoring limitationThe device does not itself monitor the patient.

Coverage contextConnected medical devices must be consistent with existing DME regulations and policies to be covered under the TRICARE Program.

Deluxe, luxury, or immaterial feature

DefinitionA deluxe, luxury, or immaterial feature is a comfort, convenience, luxury, or other optional feature that makes a durable-equipment item more expensive than the medically necessary item.

Medical standardThe feature exceeds what is medically necessary for the patient's treatment or basic mobility.

Cost effectThe feature increases the cost of the item relative to a similar item without those features.

Comfort and convenience item

DefinitionA comfort and convenience item is an optional item that a patient may elect at an additional charge.

Medical necessityThe item is not medically necessary to treat the patient's condition.

Coverage distinctionComfort and convenience items exceed what is medically necessary and increase the cost relative to similar equipment without those features.

Permanent vehicle conversions and lifts used to transport the beneficiary rather than the wheelchair are not eligible.

Mobile medical applications and connected devices

MMA, sensor, and connected-device coverage requires satisfaction of all applicable DME and MMA rules.

MMA and connected technology: The MMA is condition-specific, medically necessary, proven safe and effective, prescribed by an authorized provider, FDA approved or cleared, HIPAA compliant, and listed as eligible; sensors and connected medical devices comply with applicable DME regulations and policies; and any combined equipment-and-MMA unit is eligible as a whole.Monthly subscriptions are evaluated after 3 months and every 12 months thereafter; annual subscriptions are evaluated annually.

No MMAs are currently listed as meeting TRICARE coverage criteria.

MMA medical necessity

Covered MMAs must satisfy all listed eligibility requirements.

MMA medical necessity: The MMA treats a specific health condition, is medical in nature, and is medically or psychologically necessary; it is prescribed by a TRICARE-authorized provider acting within the scope of the provider's license; it is FDA approved or cleared; and it complies with HIPAA requirements.

No MMAs currently meet all TRICARE coverage criteria.

Upgrade medical necessity

An upgrade must be medically necessary in addition to the underlying DE item meeting benefit requirements.

Upgrade necessity: The prescription specifically documents why the upgrade is medically necessary and why the standard equipment is inadequate; for a wheelchair, the upgrade is required for the beneficiary to maintain basic mobility.

Without documentation supporting medical necessity, the base-model allowed amount applies.