Clinical UM Guideline |
Subject: Durable Medical Equipment | |
Guideline #: CG-DME-10 | Publish Date: 10/01/2024 |
Status: Reviewed | Last Review Date: 08/08/2024 |
Description |
This document defines general principles used to determine the medical necessity of durable medical equipment (DME) and includes a general definition of DME, which is based on standard contract definitions of DME and the definition from the Centers for Medicare & Medicaid Services (CMS).
Note: As these criteria may not be the criteria used in the definition of DME within the covered individual’s plan document, these criteria are not to be used for benefit determinations for a covered individual. Please see the definition of “durable medical equipment” in the covered individual’s plan document for the purpose of making benefit determinations.
Clinical Indications |
Definition:
Durable medical equipment is any equipment that meets all the following requirements:
DME must meet the following definitions of “durable” and “medical equipment”:
Medically Necessary:
Durable medical equipment is considered medically necessary when all of the following criteria are met:
The information should include the individual’s diagnosis and other pertinent functional information including, but not limited to, duration of the individual’s condition, clinical course (static, progressively worsening, or improving), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc.
Not Medically Necessary:
Items not meeting the above criteria are considered not medically necessary including, but not limited to any of the following situations:
Note: To the extent a particular type of DME is considered not medically necessary or investigational and not medically necessary, it may be addressed in a specific Medical Policy or Clinical UM Guideline.
Coding |
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
When services may be Medically Necessary when criteria are met:
HCPCS |
|
| Including, but not limited to: |
K0900 | Customized durable medical equipment, other than wheelchair |
| Note: applies to any code for durable medical equipment when there is not a more specific document available |
|
|
ICD-10 Diagnosis |
|
| All diagnoses |
When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.
Discussion/General Information |
The medical necessity of DME is based on an analysis of the following factors:
Definitions |
Activities of daily living (ADLs): Self-care activities such as transfers, toileting, grooming and hygiene, dressing, bathing, and eating.
Instrumental activities of daily living (IADLs): Activities related to independent living and include preparing meals, managing money, shopping, doing housework and using a telephone; IADLs do not involve personal care activities.
References |
Government Agency, Medical Society, and Other Authoritative Publications:
Index |
DME
Durable Medical Equipment
History |
Status | Date | Action |
Reviewed | 08/08/2024 | Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section. |
Revised | 08/10/2023 | MPTAC review. Revised gender-specific language in the Clinical Indications and updated References section. |
Reviewed | 08/11/2022 | MPTAC review. Updated References section. |
Reviewed | 08/12/2021 | MPTAC review. Updated References section. |
Reviewed | 08/13/2020 | MPTAC review. Updated References section. Reformatted Coding section. |
Reviewed | 11/07/2019 | MPTAC review. Updated References section. |
Reviewed | 01/24/2019 | MPTAC review. Updated References section. |
Reviewed | 02/27/2018 | MPTAC review. Updated header language from “Current Effective Date” to “Publish Date.” Updated Description and References sectios. |
Reviewed | 02/02/2017 | MPTAC review. Updated formatting in Clinical Indications section. Updated Description and References sections. |
Revised | 02/04/2016 | MPTAC review. Defined abbreviation in clinical indications criteria section. Updated References section. Removed ICD-9 codes from Coding section. |
Reviewed | 02/05/2015 | MPTAC review. Updated Description. |
Reviewed | 02/13/2014 | MPTAC review. Updated Description and Websites. |
| 07/01/2013 | Updated Coding section with 07/01/2013 HCPCS changes. |
Revised | 02/14/2013 | MPTAC review. Clarified not medically necessary statement and criteria deleting term DME and replacing with “item”. Updated Websites. |
Reviewed | 02/16/2012 | MPTAC review. Updated websites. |
Reviewed | 02/17/2011 | MPTAC review. Clarified Note in clinical indication section. Update Websites and References. |
Revised | 02/25/2010 | MPTAC review. Clarified definition of durable medical equipment in Clinical Indications section and clarified Medically Necessary statement. Updated description, background and references. |
Reviewed | 02/26/2009 | MPTAC review. References updated. |
Reviewed | 02/21/2008 | MPTAC review. References updated. |
Revised | 03/08/2007 | MPTAC review. Clarified definition, medically necessary criteria, not medically necessary criteria and the discussion section. |
Reviewed | 12/07/2006 | MPTAC review. References updated. |
New | 12/01/2005 | MPTAC initial guideline development. |
Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.