CurrentEmpire BluecrossPolicy G-06052

Durable Medical Equipment (Rent to Purchase)

Governs reimbursement for rental-to-purchase durable medical equipment (DME) for Anthem Medicare Advantage members, outlining rental limits, included components, exclusions, and special rules (e.g., oxygen). Affects providers submitting claims to Empire Bluecross/Anthem Medicare Advantage.

Policy Summary

PayerEmpire Bluecross

PolicyDurable Medical Equipment (Rent to Purchase)

Policy CodePolicy G-06052

Change TypeClarified (oxygen rental) & template updates

Effective Date06/13/2023

Next Review Date

Key ActionReimburse rental DME based on the monthly rental price up to the maximum allowed; item is considered purchased once the purchase price is met.

SourceLink

POLICY UPDATE CHANGES

Added clarification language for oxygen rental.

Policy template updated (general template updates noted in history).

13 monthsmaximum rental reimbursement period for most DME (Medicare products)

36 monthsmaximum rental reimbursement period for oxygen equipment

24 monthsadditional reimbursement allowed for oxygen contents and supplies

G-06052policy identifier

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.

Rental DME Reimbursement Criteria

Rental DME reimbursement criteria and limits

Covered when the following rental reimbursement limits and rules are met:

Rental reimbursement is based on the rental price up to the maximum allowed; the item is considered purchased once the purchase price has been met.

Maximum rental period for most DME (Medicare products) is 13 months; after 13 months claims for the item will be denied and the item will be considered purchased.

Maximum rental period for oxygen equipment is 36 months; oxygen contents and supplies may be reimbursed for up to an additional 24 months beyond the equipment period.

If a member changes suppliers during the rental period, the new rental period does not start over.

A break in coverage greater than 60 days during the rental period will reset the rental limitation count (the limitation count will start over).

Supplies and accessory components associated with rental DME are considered all-inclusive in the rental reimbursement and are not separately reimbursed.

Nonreimbursable circumstances include repair or replacement necessitated by abuse or neglect; repair or replacement during the warranty period; provision of DME that exceeds benefit limits unless authorized; aesthetic enhancements, convenience upgrades, experimental/investigational items, DME normally included in facility charges, and common household items not medically indicated.

Coding and Rental Month Limits

Required coding systemsmixed

CPT/HCPCS/Revenue

Claims must use industry standard CPT, HCPCS, and/or revenue codes for DME reimbursement.

Rental month limits — inv-03: Rental month limits

Most DME (Medicare products)Maximum rental reimbursement period is 13 months; after 13 months claims for the item will be denied and the item is considered purchased.

Oxygen equipmentMaximum rental reimbursement period is 36 months.

Oxygen contents and suppliesReimbursement for oxygen contents and supplies may continue for an additional 24 months beyond the equipment period, as applicable.

Provider Billing and Reimbursement Actions

Prior Authorization

Rental reimbursement and authorization requirements

Reimbursement is based on the rental price up to the maximum allowed; the item is considered purchased once the purchase price has been met. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence. Use industry-standard CPT, HCPCS, and/or revenue codes on all claim submissions; failure to follow coding/billing guidelines may result in recoupment, rejection, denial, or adjusted reimbursement.

Reimbursement follows the rental price up to the plan’s maximum for that DME; once the purchase price is met the item is deemed purchased (no further rental reimbursement).
Ensure services meet authorization and medical necessity guidelines for the procedure, diagnosis, and member’s state of residence.
Bill with Current Procedure Terminology (CPT), HCPCS, and/or revenue codes as applicable; improper coding may lead to recoupment or denial.

Key Definitions

inv-06: Durable Medical Equipment (DME)

DefinitionDurable Medical Equipment (DME): Items that are primarily and customarily used to serve a medical purpose, can withstand repeated use, are generally not useful to a person without an illness or injury, are appropriate for home use, and are prescribed by a licensed physician/practitioner. All requirements must be met before an item can be considered DME.

inv-07: Rent-to-purchase

Rent-to-purchaseA time period during which reimbursement is based on a monthly fee up to the amount at which the item will be considered purchased.

inv-08: Capped rental

Capped rentalAn amount reimbursed on a monthly rental basis that will not exceed the applicable number of continuous months; if the service is billed beyond the maximum number of rental months, no additional reimbursement will be allowed.