ALL of the following

• Orthotic replacements are included in the reimbursement for orthotics.
• Orthopedic shoes and accessories for members with diabetes are reimbursable when reported with codes specific to diabetic footwear.
• Only one pair of therapeutic shoes for members with diabetes is reimbursable per calendar year; therapeutic shoe inserts or modifications for members with diabetes are reimbursable up to six units per calendar year; diabetic shoe inserts/modifications reported with non-diabetic footwear are not eligible for reimbursement.

ALL of the following

• External defibrillators are eligible for reimbursement when the member meets coverage criteria and when submitted with the appropriate modifier.

ALL of the following

• Glucose monitors and supplies are reimbursable for diabetics only and must be reported with the appropriate modifier (KS or KX).
• Continuous noninvasive glucose monitors are considered experimental/investigational and are not covered.
• Disposable glucose monitors are non-covered items.
• Only one home blood glucose monitor is reimbursable per 12-month period.

ALL of the following

• Enteral feeding supply kits are reimbursable once per day; additives for enteral formula are included in formula reimbursement; components of a more complete kit are included in the kit reimbursement.
• Parenteral nutrient solution is reimbursable at one unit per day; one supply kit and one administration kit are reimbursable for each day parenteral nutrition is administered; premix solutions and components are included in the reimbursement for the complete premix solution.

ALL of the following

• Hospital bed rental is reimbursable once per month; hospital bed rails and mattresses and headboards/accessories described in the bed are included in the reimbursement for hospital beds when applicable.
• Oxygen stationary system rental (and portable oxygen rental) is reimbursable once per month; accessories, supplies used to administer oxygen, and oxygen contents are included in the monthly rental reimbursement; oxygen modifiers QE/QF/QG are recognized only with stationary oxygen rentals; oximeters and replacement probes are not covered.

ALL of the following

• Certain power wheelchair accessories are non-covered (including power seat elevation and power standing systems).
• Patient lifts that are electric with seat, multi-positional integrated lifts, toilet lifts, and free-moving or fixed lifts are non-covered; slings are included in the reimbursement for a patient lift when applicable.

ALL of the following

• A segmental pneumatic appliance is eligible for reimbursement when reported with a segmental pneumatic compressor; a non-segmental pneumatic compression appliance is eligible when reported with a non-segmental pneumatic compressor; only one type of pneumatic compressor (lymphedema pump) is eligible for reimbursement in the same month.
• The TENS monthly supply allowance includes electrodes, conductive paste/gel, tape/adhesive, adhesive remover, skin prep materials, batteries, and a battery charger.

ALL of the following

• Rental DME is considered for reimbursement once per month.
• Maintenance and servicing (modifier MS) is eligible for reimbursement after seven months have elapsed since the last rental payment and only at a frequency of once every six months.
• Repair of DME is included in the initial provision of DME; labor for prosthetic repair is included when reported within 90 days of the prosthesis; replacement of DME/prostheses is eligible after the useful lifetime has been reached (typically five years).

ALL of the following

• Urinary catheter insertion trays: considered for reimbursement at a frequency of two per calendar month; an additional two Foley catheters may be considered in the same month; sterile intermittent catheters reimbursable up to 600 times within 90 days; bedside drainage bags up to 6 units in 3 months; adhesive tape used with ostomy or urological supplies eligible up to 40 units per month.
• Components or accessories that are part of a more complete kit or appliance (ostomy, infusion kits, IV poles, replacement batteries for infusion pumps) are included in the reimbursement for that kit/appliance.

ALL of the following

• Disposable large volume nebulizers are non-covered items; corrugated tubing for large volume nebulizer reimbursable per stated frequency; controlled inhalation medication delivery systems are eligible when reported with the appropriate medication.
• A 90-day dispensing fee is reimbursable once per 90 days; a 30-day pharmacy dispensing fee for inhalation medications is reimbursable once per month; nebulizer medication unit limits are medication-specific (e.g., metaproterenol sulfate up to 740 units per 3 months; examples of other medication limits provided).

ALL of the following

• Prosthetics and orthotics that can be reported bilaterally require RT/LT modifiers; lower limb prostheses require functional modifiers K0–K4; items requiring an order prior to delivery (pressure reducing surfaces, power operated vehicles, seat lift mechanisms, TENS units) are reimbursable when a written order is on file prior to delivery and should be reported with modifier EY; adhesive tape for DMEPOS providers requires AU/AV/AW/AX modifiers and is not reimbursable in an office setting; KS/KX modifiers apply for diabetic blood glucose supplies.

ALL of the following

• Continuous noninvasive glucose monitors are considered experimental/investigational and are not covered; certain items (disposable glucose monitors, specified wheelchair accessories, specified patient lifts, oximeters and replacement probes) are non-covered as described above.

ALL of the following

• Policy references HCPCS Level II, DME MAC, and Medicare National Coverage Determinations Manual (NCD) as supporting sources.
• Health Net does not require documentation at the time of claim submission; documentation may be requested if a claim is audited. All claims remain subject to prior authorization requirements where applicable.

ALL of the following

• Orthopedic footwear and associated inserts/modifications for members with diabetes are reimbursable when member meets coverage criteria and when submitted with the appropriate modifier; an insert that is direct formed/molded without external heat source is a non-covered item.