CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Durable Medical Equipment (DME) coverage

Defines Neighborhood Health Plan of Rhode Island's coverage, limitations, and non-covered HCPCS codes for Durable Medical Equipment (DME) for applicable benefit packages and describes ordering/setting rules and vendor/medical review processes.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyDurable Medical Equipment (DME) coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization for conditionally covered incontinence products (see A4520, A4554) before billing as DME.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

multipleexplicit non-covered DME items listed

severalBenefit packages listed

homeHome is primary POS

authIncontinence require auth

Coverage Criteria

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DME general coverage criteria: Equipment can withstand repeated use; is primarily and customarily used to serve a medical purpose; generally is not useful in the absence of illness or injury; and is appropriate for use in the member's home. Includes enteral & parenteral supplies, prosthetics & orthotics.

Benefit packages: RIte Care, Substitute Care, Children with Special Health Care Needs, Rhody Health Partners; Extended Family Planning (EFP) generally excludes DME (see EFP benefit coverage summary).

Ordering and utilization: DME must be ordered by a practitioner or delivered/utilized by a practitioner during an episode of care. Both primary care and specialty practitioners may order/utilize DME. Episodes of care include professional (POS 11), home (POS 12), urgent care (POS 20), inpatient (POS 21), outpatient (POS 22), and federally qualified community health center (POS 50).

The largest volume of DME is delivered to and utilized in the member's home; DMEnsion Benefit Management processes home DME claims and manages the vendor network; Neighborhood Medical Management with the Associate Medical Director makes medical review decisions.

Non-Covered DME Items

The following HCPCS codes are explicitly non-covered in any place of service

Non-covered HCPCS codes: HCPCS codes listed in the non-covered tables (see Table 1 and continuation) are non-covered regardless of place of service.

Codes listed across source chunks 4-6 include (not exhaustive here): A4336, A4360, A4495, A4500, A4510, A4575, A4670, A6000, A6413, A9270, A9275, A9281, A9283, A9300, C9365, E0231, E0232, E0241, E0242, E0243, E0273, E0274, E0315, E0936, E1300, L7600, L7900, T4521–T4543, T5001, T5999. Items on this list are considered not covered/not medically necessary when billed as DME.

See Non-covered items table: specific HCPCS codes listed in Table 1 are excluded from coverage (any place of service). Table 1 lists HCPCS codes such as A4336, A4360, A4495, A4500, A4510, A4575, A4670, A6000, A6413, A9270, A9275, A9281, A9283, A9300, C9365, and E0231 as non-covered items.

HCPCS codes listed in the non-covered tables are considered not covered/not medically necessary when billed as DME. The non-covered lists include the series of incontinence product codes (T4521–T4543 and related T45xx/T46xx entries), supplies and miscellaneous codes (A9270, A4336), bath/rail and bed accessories (E0241, E0242, E0243, E0273, E0274, E0315), and other items shown in Table 1; these will be treated as not medically necessary when billed as DME.

Coding and HCPCS Lists

Non-Covered HCPCS Codes (part 1)HCPCSNot Covered

A4336	Incontinence supply; miscellaneous.
A4360	Disposable external urethral clamp or compression device, with pad and/or pouch, each.
A4495	Surgical stockings thigh length, each.
A4500	Surgical stockings below knee length, each.
A4510	Surgical stockings full length, each.
A4575	Topical hyperbaric oxygen chamber, disposable.
A4670	Automatic blood pressure monitor.
A6000	Non-contact wound warming wound cover for use with the non-contact wound.
A6413	Adhesive bandage, first-aid type, any size, each.
A9270	Non-covered item or service.

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Non-Covered HCPCS Codes (part 2)HCPCSNot Covered

E0232	Warming card for use with the non contact wound warming device and non contact.
E0241	Bath tub wall rail, each.
E0242	Bath tub rail, floor base.
E0243	Toilet rail, each.
E0273	Bed board.
E0274	Over-bed table.
E0315	Bed accessory: board, table, or support device, any type.
E0936	Continuous passive motion exercise device for use other than knee.
E1300	Whirlpool, portable (overtub type).
L7600	Prosthetic donning sleeve, any material, each.

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Non-Covered HCPCS Codes (part 3)HCPCSNot Covered

T4523	Adult sized disposable incontinence product.
T4524	Adult sized disposable incontinence product.
T4525	Adult sized disposable incontinence product.
T4526	Adult sized disposable incontinence product.
T4527	Adult sized disposable incontinence product.
T4528	Adult sized disposable incontinence product.
T4529	Pediatric sized disposable incontinence product.
T4530	Pediatric sized disposable incontinence product.
T4531	Pediatric sized disposable incontinence product.
T4532	Pediatric sized disposable incontinence product.

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inv-08: Quantity limits — Established per individual HCPCS code largely based on industry standard and CMS/DHS guidelines

Quantity limit policyQuantity limits are established per individual HCPCS code largely based on industry standard with modifications for member needs and using CMS and DHS guidelines where applicable

Limitation categoriesCoverage limitations fall into three categories: non-covered items, conditionally covered items requiring authorization, and items with quantity limits

Authority for lists and limitsThe list of non-covered items and related limits is approved by the Chief Medical Officer or designee based on CMS Medicare and DHS guidelines and Neighborhood review

ApplicationQuantity limits apply to DME claims and are used alongside authorization rules for conditionally covered items

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required

Authorization required for certain conditionally covered items. Incontinence products (see HCPCS codes A4520, A4554 and T45xx series) require prior authorization per the DME Clinical Medical Policy. Contact DMEnsion Benefit Management or Neighborhood Medical Management for medical review and authorization decisions for home-delivered DME.

Affected codes include A4520, A4554 and T4523–T4543, T5001, T5999
Home-delivered DME claims are processed by DMEnsion Benefit Management
All medical review decisions are made by Neighborhood's Medical Management in conjunction with the Associate Medical Director

Documentation Required

Provider Ordering and Episode-of-Care Requirements

DME must be ordered by a practitioner or delivered/utilized by a practitioner during an episode of care. Both primary care and specialty practitioners may order or utilize DME. Episodes of care include office, home, urgent care, inpatient, outpatient, and federally qualified community health center settings.

Applicable POS: 11, 12, 20, 21, 22, 50
Largest volume of DME is delivered and utilized in the member's home

Denial Risk

Non-covered Items — CMO Designation

Items designated as non-covered are approved by the Chief Medical Officer or designee based on CMS Medicare guidelines, DHS guidelines, and Neighborhood review. Items so designated will be denied when billed unless overturned through the established appeal or prior authorization process.

Non-covered item list is maintained and approved by the Chief Medical Officer or designee
Denial of non-covered items follows CMS/DHS guidance and Neighborhood review process

Background

Durable Medical Equipment (DME) is equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, is generally not useful without illness or injury, and is appropriate for home use; it includes enteral and parenteral supplies, prosthetics, and orthotics. DME must be ordered by a practitioner or delivered/utilized by a practitioner during an episode of care, and coverage is subject to the general criteria and benefit package applicability described in the policy.

Definitions

inv-14: Durable Medical Equipment (DME) — Equipment that can withstand repeated use, is primarily for medical purposes, not useful without illness or injury, and appropriate for h...

DefinitionDurable Medical Equipment (DME): equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, is generally not useful in the absence of illness or injury, and is appropriate for use in a patient’s home

Examples includedIncludes enteral and parenteral supplies, prosthetics, and orthotics

Ordering and useDME must be ordered by or delivered/utilized by a practitioner during an episode of care; both primary care and specialty practitioners may order/utilize DME

Episode of care settingsEpisodes of care may occur in professional office (POS 11), home (POS 12), urgent care (POS 20), inpatient (POS 21), outpatient (POS 22), and federally qualified CHC (POS 50)

Vendor and reviewLargest volume of DME is delivered to the member’s home; DMEnsion Benefit Management processes home DME claims and manages the vendor network while Neighborhood Medical Management (with Associate Medical Director) performs medical review

inv-15: Episode of care — An episode of care during which DME is ordered or delivered/utilized, can occur across multiple settings including professional office, h...

Episode of care definitionAn episode of care is the period during which DME is ordered or delivered/utilized and may span multiple settings including professional office, home, urgent care, inpatient, outpatient, and federally qualified CHC

Who may order/utilizeBoth primary care and specialty care practitioners can order or utilize DME during an episode of care

Home as primary settingThe largest volume of DME is delivered to and utilized in the member’s home (POS 12)