Personal Emergency Response System (PERS) — DMEPOS Coverage Criteria
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This policy defines medical necessity, device/vendor standards, documentation, and coverage requirements for in-home Personal Emergency Response Systems (PERS) provided as DMEPOS for Northwood members.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medical necessity criteria
Covered when ALL of the following are met
From policy section A (see source).
Device / vendor requirements (DMEPOS)
PERS must include ALL of the following device features and vendor capabilities
From policy section B (DMEPOS requirements).
PERS is not covered when it duplicates emergency equipment already available to the member. Examples include, but are not limited to, existing emergency call buttons or other electronic means by which the member can summon help in an emergency.
PERS is not covered when the member has access to help on a 24-hour-per-day, seven-day-per-week basis; in such cases the service would be redundant and coverage is excluded.
Coding
Provider Actions & Billing Rules
Obtain completed, dated, and signed PERS General Prescription before installation
A completed, dated, and signed PERS General Prescription form must be obtained from the prescribing provider before installation; the form must be renewed and re-signed if the member's medical condition or living situation changes such that coverage requirements may no longer be met.
Do not bill installation if member/caregiver can install (mail delivery allowed)
Providers must assess whether someone (member, caregiver, or family) is available to install the PERS; if other options exist, the device may be shipped to the member and the provider must not bill for installation. Return receipt is required when delivering by mail.
- Installation reimbursement only when the provider's assessment documents no one else is available to install.
- If delivered by mail, obtain return receipt and do not submit a claim for installation.
Keep signed PERS General Prescription in member record and produce on request
The DME provider must maintain the completed, dated, and signed PERS General Prescription form in the member's record and make it available upon request.
Provide UL 1637 compliance documentation on request
Upon request, providers must supply documentation demonstrating compliance with applicable safety standards (UL Standard 1637).
Coverage denied when PERS duplicates existing emergency equipment or 24/7 help is available
Do not cover PERS when it duplicates equipment already available to the member for emergency use, or when the member has access to help 24 hours per day, seven days per week.
- Duplicates existing emergency equipment (e.g., emergency call buttons or other electronic means of calling for help).
- Member has continuous (24/7) access to help.
Definitions
Medical Necessity
PERS medical necessity
Top-level node referencing PERS medical necessity requirements; all conditions must be met.
Rental and Purchase Rules
| Equipment | Purchase vs Rental (coverage determination) |
|---|---|
| Personal Emergency Response System (PERS) | Determined by member's contract and benefit language; the policy states that coverage determinations (including whether equipment is purchased or rented) are made on a case-by-case basis and are subject to the terms of the member's contract. |
| Notes | The policy notes that a conclusion of medical necessity does not itself constitute coverage and that contract language prevails when conflicts exist. |
| Billing item | When installation may be billed |
|---|---|
| Installation (PERS) | The DME-PERS provider will be reimbursed for installation only if the provider's assessment documents that there is no one else available to install the PERS in the member's home (for example the member, caregiver, or family). The assessment must be maintained in the member's record. |
| Delivery by mail | If other options exist for members to install PERS (member/caregiver/family), providers may deliver PERS by mail (return receipt required) and must not submit a claim for installation. |
Documentation Requirements
Maintain prescription, UL compliance, and installation assessment documentation
Maintain a completed, dated, and signed PERS General Prescription in the member's record and be prepared to provide documentation of UL 1637 compliance upon request; when billing for installation, document the assessment that no one else is available to install the PERS.
- Keep the completed PERS General Prescription form in the member's file and renew it if the member's condition or living situation changes.
- Provide documentation demonstrating compliance with UL Standard 1637 when requested by Northwood.
- Document the installation assessment showing no available person to install if submitting a claim for installation; if other options exist, deliver by mail and do not bill installation.
Background
Personal Emergency Response Systems (PERS) provide a 24-hour emergency communication link for members with medical conditions that cause significant functional limitations or incapacitation and prevent use of other emergency-summoning methods. A typical PERS includes a base unit and a wearable activator that connect the member to a professionally staffed monitoring center which assesses situations and directs responses.
To meet DMEPOS requirements, a PERS must be durable medical equipment with an in-home communications transceiver and a remote, portable activation device; it must have the capacity to respond to incoming emergency signals, handle simultaneous signals without disconnection, routinely self-test to central monitoring, and be supported by a central monitoring station with trained attendants and 24/7 staffed back-up systems.
Not Covered
NOT COVERED: PERS that duplicates existing emergency equipment available to the member (for example, emergency call buttons or other electronic means of calling for help) and PERS for members who already have access to help on a 24-hour-per-day, seven-day-per-week basis.
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