Durable Medical Equipment (DME)
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Defines coverage, prior authorization requirements, and Medicare-based coverage criteria for durable medical equipment provided for members, including a special note on Automatic External Defibrillators (Life Vest). Applies to Longevity Health Plan of Colorado members and providers seeking coverage for DME.
Addition of coverage criteria for Automatic External Defibrillators.
Coverage Criteria for Durable Medical Equipment
General DME coverage criteria
Covered when ALL of the following Medicare-based conditions are met:
Reference: Medicare Benefit Policy Manual Chapter 15
Institutional status per §1819(a)(1) and Medicare certification guidance
Per Medicare Program Integrity Manual Chapter 5
Per Longevity Health policy and Medicare Benefit Policy Manual Chapter 15
DME is excluded from separate Medicare Part B payment when it is supplied to beneficiaries who are in institutions that do not qualify as the beneficiary’s home under Medicare rules. As defined by the Medicare Benefit Policy Manual Chapter 15, DME must be provided in a beneficiary’s home; institutions meeting the Chapter 15 criteria are not considered the beneficiary’s home and therefore separate Part B payment is not allowed.
A beneficiary who is a patient in an institution that meets the Medicare definitions of a hospital (§1861(e)(1) of the Social Security Act) or a skilled nursing facility (§1819(a)(1) of the Act) is not eligible for separate Part B payment for rental or purchase of DME. Medicare‑certified hospitals and SNFs are automatically considered to meet these requirements; consequently, DME provided while the member is an inpatient in such institutions is not separately payable under Part B.
Provider Requirements and Actions
Prior authorization required
Prior authorization is required for all durable medical equipment (DME) items; submit a prior authorization request before providing DME (common examples: hospital beds, wheelchairs, ventilators, oxygen equipment).
- Submit PA with clinical justification and expected home use when applicable.
Include Medicare Chapter 15 evidence with PA
Ensure prior authorization includes documentation demonstrating the item meets Medicare Chapter 15 DME definitions (durable, medically necessary, appropriate for home use) and that orthotic/prosthetic exceptions are noted when applicable.
- If the member resides in a nursing facility, document Medicare certification status and whether the device is an orthotic/prosthetic (these devices are exempt from the home‑use requirement).
- Include reference to Medicare Benefit Policy Manual Chapter 15 criteria when requesting authorization.
Documentation to support DME home use (Medicare Benefit Policy Manual Chapter 15)
When requesting prior authorization, provide documentation that demonstrates medical necessity consistent with the Medicare Benefit Policy Manual Chapter 15 and that the item is appropriate for use in the beneficiary's home when required.
- Document that the equipment is for use in the beneficiary's home (place of residence) per Chapter 15 definitions.
- If the beneficiary is in an institution, include documentation explaining residency status and why the home‑use requirement is met or why an exception applies.
Denial risk if DME provided to inpatient hospital or SNF
Do not bill for separate Part B payment for DME provided to beneficiaries who are inpatients of hospitals or Medicare‑certified skilled nursing facilities; such institutions are not considered the beneficiary's home and claims will be denied.
- If facility is Medicare‑certified hospital or SNF, separate Part B payment for rental or purchase of DME is not allowed.
- For members in nursing facilities, consider orthotic/prosthetic exception only with prior authorization as noted in Medicare Program Integrity Manual Chapter 5.
Medical Necessity — Special Items
Automatic External Defibrillator (Life Vest)
Life Vest/AED specialized criteria must meet referenced policy L33690.
See L33690 for full clinical criteria
Rental and Purchase Rules (Orthotics & Prosthetics)
| Equipment | Rule | Notes / Exceptions |
|---|---|---|
| Orthotics and prosthetics | ||
| {"text":"Not subject to the Medicare "home use" requirement; may be covered for members in nursing facilities","status":""} | ||
| Coverage determined per Medicare LCDs/NCDs and Medical Benefit Policy Manual; prior authorization required |
Documentation Requirements
Submit prior authorization with documentation of home use and medical necessity
When submitting prior authorization, include clinical documentation that supports medical necessity and that the item is appropriate for home use per Medicare Benefit Policy Manual Chapter 15.
- Attach clinical notes, functional assessments, and any other records showing need and home-use suitability.
- Reference Chapter 15 language in the submission to align coverage determinations with Medicare standards.
Key Definitions
Background
Durable Medical Equipment (DME) refers to equipment that meets the Medicare definitions in the Medicare Benefit Policy Manual Chapter 15 and is appropriate for use in the beneficiary’s home. Providers should note that prior authorization is required for DME items, and coverage determinations follow Medicare Chapter 15 standards regarding durability, medical purpose, and home use.
Items Not Covered
Separate Medicare Part B payment is not allowed for DME items furnished to a beneficiary who is an inpatient of a hospital or a Medicare‑certified skilled nursing facility. Hospitals and SNFs that are Medicare‑certified are automatically considered to meet the statutory requirements that preclude the institution from being treated as the patient’s home; therefore DME provided in those settings is not separately payable under Part B.
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