MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Durable Medical Equipment Repair/Replacement (Excluding Wheelchairs and C/BiPap Machines)

Number 1.01.526*

Effective Date September 9, 2013

Revision Date(s) N/A

Replaces N/A

*Medicare has a policy.

Policy

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Repairs to a covered, member-owned durable medical equipment (DME) item may be considered medically necessary when, due to reasonable wear or due to accidental damage, repairs are required to make the DME item functional.

Replacement of covered, member-owned DME item may be considered medically necessary if due to reasonable deterioration over time or accidental damage the item is non-functional and cannot be repaired.

Accessory add-ons and upgrades of an existing DME item may be considered not medically necessary when a current DME item is functional and meets the member’s current basic functional medical needs.

Related Policies

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1.01.501

Wheelchairs (Manual or Motorized)

1.01.523

Heating Pads, Heat Lamps, Paraffin Bath, Hydrocollator Treatments in the Home

1.01.524

Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea

1.01.527

Power Operated Vehicles (Scooters) (excluding motorized wheelchairs)

2.01.503

Diagnosis and Medical Management of Obstructive Sleep Apnea Syndrome and Upper Airway Resistance Syndrome

Policy Guidelines

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The durable medical equipment (DME) supplier or repair facility must document the reason for the repair; or replacement if the item cannot be repaired. If the repair cost exceeds the replacement cost, no payment is made for the amount in excess of the replacement cost.

Additional suggested points to consider when reviewing for benefit determination:

Repair of durable medical equipment

  • Repairs are needed to make the equipment functional, due to reasonable wear and usage
  • The DME being repaired is member-owned
  • The item needs repair and the manufacturer’s warranty has expired
  • The repair cost is less than the replacement cost
  • The repair is needed due to a change in the member’s condition

Replacement of durable medical equipment

  • The item cannot be repaired due to reasonable deterioration over time or accidental damage
  • The DME being replaced is member-owned
  • The item cannot be repaired and the manufacturer’s warranty has expired
  • The replacement cost is less than the repair cost
  • The replacement is needed due to a change in the member’s condition that makes the current DME no longer useable
  • Replacement of the DME item is subject to review of the supplier’s affidavit stating why the current DME item is no longer useable/repairable
  • The DME item is lost or stolen and not otherwise covered by another insurance (such as a homeowner’s policy)

Rental during repair or replacement

  • 1-month rental of equipment may be covered while a member-owned DME item is being repaired or while waiting for a replacement of the current member-owned DME it.

NOTE: Wheelchair repair and replacement is addressed in a separate policy. (See Related Policies) Devices to treat obstructive sleep apnea are addressed in a separate policy. (See Related Policies)

Description

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DME must be used to meet the primary medical needs of the member, rather than being for comfort or convenience. DME must meet all of these criteria:

  • The item is durable (long-lasting) and can withstand repeated use
  • Not usually useful to a member who isn’t sick/injured/incapacitated
  • Used for a medical reason to meet the member’s condition-specific functional impairment
  • The item is appropriate for use in the member’s home or for limited use in the community for basic activities of daily living (ADLs)

Medicare National Coverage

For member owned “Medicare-covered durable medical equipment and other devices, Medicare may cover repairs and replacement parts. Equipment may be replaced if it’s lost, stolen, damaged beyond repair, or used for more than the reasonable useful lifetime of the equipment”. (2)

Scope

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Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

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Coverage for repair or replacement of member-owned durable medical equipment is subject to the limits and conditions of the member benefit plan. (See Scope).

Repair or replacement of a member-owned duplicate DME item, such as a back-up or redundant DME item that is not the primary device used to meet the member’s functional needs, may not be covered by some benefit plans. (See Scope).

Rationale

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N/A

References

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  1. Medicare/Noridian Administrative Services. DME Repair and Replacement Frequently Asked Questions. Available at URL address: https://www.noridianmedicare.com/dme/news/docs/2007/10_oct/repair_replace_faqs.html. Last accessed July 2, 2013.
  2. Medicare Benefit Policy Manual. Chapter 15 – Covered Medical and Other Health Services, Section 110.2 Repairs, Maintenance, Replacement, and Delivery. Available at URL address: http://cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf. Last accessed July 2, 2013.
  3. Centers for Medicare & Medicaid Services. Durable Medical Equipment (DME) Center. Available at URL address: http://cms.gov/Center/Provider-Type/Durable-Medical-Equipment-DME-Center.html?redirect=/center/dme.asp. Last accessed July 2, 2013.

Coding

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Codes

Number

Description

 

   

Appendix

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N/A

History

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Date

Reason

09/09/13

New policy. Policy and policy guidelines detail medically necessary for repair/replacement of covered, member-owned durable medical equipment.

02/21/14

Update Related Policies. Add 1.01.527.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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