Durable Medical Equipment (DME) is defined as follows:
All requirements of the definition must be met before an item can be considered DME.
The following items may be considered medically necessary providing they meet the following criteria:
DME items not meeting the criteria as indicated in this policy are considered not medically necessary
Accessories
A4615 |
A4616 |
A4640 |
|
|
|
|
Anti-embolism Stockings
A4490 |
A4495 |
A4500 |
A4510 |
|
|
|
Canes
Quad Canes
|
Commode Chair with Seat Lift Mechanism
|
Commode Chair-on-Wheels
|
Crutches
E0110 |
E0111 |
E0112 |
E0113 |
E0114 |
E0116 |
|
Crutch, Underarm, Articulating, Spring Assisted
|
Crutch Substitute, Lower Leg Platform, with or without Wheels, each
|
Eye Pads/Patches
A6410 |
A6411 |
A6412 |
|
|
|
|
Fluidic Breathing Assistor
|
Gait Trainers
|
Gloves
|
Haberman Feeder
|
Heating Pads
Therapeutic Fomentation Device
E0210 |
E0215 |
|
|
|
|
|
Heat Lamps
|
Helmet with Face Guard and Soft Interface Material, Prefabricated
|
Hydrocollator Steam Packs
A9999 |
E1399 |
|
|
|
|
|
Injectors and Injection Aid Device
|
Intermittent Positive Pressure Breathing (IPPB) machine
E0500 |
|
|
|
|
|
|
Jaw Motion Rehabilitation System
E1700 |
E1701 |
E1702 |
|
|
|
|
Lamb's Wool Pads
E0188 |
E0189 |
|
|
|
|
|
Non-elastic Binders for Extremities
Refer to Medical Policy E-9, Non-Custom/Custom-Made Gradient Compression Garments/Stockings/Sleeves, for additional information.
A4465 |
S8430 |
S8431 |
|
Percussors (conventional)
E0480 |
|
|
|
|
|
|
Oscillatory Devices
Flutter
Intrapulmonary Percussive Ventilation System
(Oscillatory positive expiratory pressure device, non-electric, any type, each)
E0481 |
E0484 |
S8185 |
|
|
|
|
Paraffin Bath Units (portable)
E0235 |
|
|
|
|
|
|
Paraffin
A4265 |
E0235 |
|
|
|
|
|
Postural Drainage Boards
|
Rollabout Chairs, Transport Chairs
Customized pediatric strollers are covered for a child who is non-ambulatory when either of the following conditions applies:
E1031 |
E1035 |
E1036 |
E1037 |
E1038 |
E1039 |
|
Safety Rollers
All claims will be referred for medical review/individual consideration.
E1399 |
|
|
|
|
|
|
Self-Contained Pacemaker Monitor
E0610 |
E0615 |
|
|
|
|
|
Sitz Bath
E0160 |
E0161 |
E0162 |
|
|
|
|
Standers
|
Suction Machine
E0600 |
E2000 |
|
|
|
|
|
Surgical Mask
A4928 |
|
|
|
|
|
|
Thermometers
A4931 |
A4932 |
|
|
|
|
|
Traction Equipment
Refer to Medical Policy E-52 Home Cervical Traction Therapy for additional information.
E0870 |
E0880 |
E0890 |
E0900 |
E0920 |
E0930 |
E0941 |
E0942 |
E0944 |
E0945 |
E0946 |
E0947 |
E0948 |
Transfer Board or Device, any type, each
E0705 |
|
|
|
|
|
|
Trapeze Bars
E0910 |
E0911 |
E0912 |
E0940 |
|
|
|
Urinals
|
Vaporizers
E0605 |
|
|
|
|
|
|
Walkers
|
Whirlpool Bath Equipment (standard)
All claims will be referred for medical review.
|
The following is considered not medically necessary:
Continuous Passive Motion (CPM)
|
Non Covered Items
The following items are considered convenience items, comfort items, hygienic equipment or not primarily medical in nature, and are non-covered.
Description |
Code |
Adjustable high chair |
T5001 |
Alert Systems |
A9280 |
Auto-Tilt Chair |
T5001 |
Backrests |
E1399 |
Batteries, Replacement |
A4630 |
Bathtub Lifts, Wirlpool tub, walk-in, portable |
E1300, E0625, K1003 |
Bathtub/Shower chairs/seats |
E0240, E0245, E0247, E0248 |
Bath tub Rail, Wall Rail |
E0241, E0242, E0243, E0246 |
Carafes |
E1399 |
Carrie seats |
T5001 |
Corner chair |
T5001 |
Ear Plugs (standard or custom-made) |
E1399 |
Electric Adaptors (for car, truck, etc.) |
E1399 |
Elevators |
E1399 |
Enema/Enema Bags/Enema tubes |
A4458, A4459, K1013 |
Enuresis (Bed Wetting) Alarm |
S8270 |
Exercise Equipment, Exercycle |
A9300 |
Feeder seats |
T5001 |
Floor sitters |
T5001 |
Grab Bars |
E0241, E0242, E0243, E0246 |
Heavy Cast Socks-6 |
E1399 |
Hot Water Bottle, ice cap or collar, heat and/or cold wrap, any type (includes ice pack) |
A9273 |
Hygienic equipment |
A9286 |
Hygienic supply |
A9286 |
Light Cast Sock-6 |
E1399 |
Linen, nonallergenic |
E1399 |
Lumbar Roll |
E0190 |
Lumex Ortho-Biotic High Back Rockers |
E1399 |
Lumex Ortho-Biotic Recliners |
E1399 |
Massage Chair/Robotic Chair |
E1399 |
Massage Devices |
E1399 |
Massage Mattress |
E1399 |
Massage Table |
E1399 |
Mileage |
E1399 |
Mobile Monomatic Sanitation System |
E1399 |
Niagara Massage Pillow |
E1399 |
Niagara Thermo-Cyclopad |
E1399 |
Positioning cushion/pillow/wedge, any shape or size |
E0190 |
Positioning Support System |
T5001 |
Posture support chair |
T5001 |
Raised Toilet Seats |
E0244 |
Reaching/Grabbing device, any type, any length, each |
A9281 |
Safety car seats |
E1399 |
Sauna Baths |
E1399 |
Silverware/Utensils |
E1399 |
Standard feeder seats |
T5001 |
Standard high chairs |
T5001 |
Telephone Arms |
E1399 |
Toilet Seats |
E1399 |
Treadmill Exerciser |
A9300 |
Tub rail attachment |
E0246 |
Tub Stool or Bench |
E0240, E0245, E0247, E0248 |
Versa Form chairs |
T5001 |
Zero gravity chair |
E1399 |
The following items are considered environmental control equipment, and are non-covered.
Description |
Code |
Air Cleaners |
E1399 |
Air Conditioners |
E1399 |
Dehumidifiers |
E1399 |
Environmental control equipment |
E1399 |
Heating and Cooling Plants |
E1399 |
Humidifiers |
E1399 |
Portable Room Heaters |
E1399 |
The following items are considered educational equipment; and are not primarily medical in nature and are non-covered.
Description |
Code |
Braille Teaching Texts |
E1399 |
Communic-Aid |
E1902 |
Communicator |
E1902 |
The following items are considered inappropriate for home use or physician instruments or institutional equipment and are non-covered.
Description |
Code |
Esophageal Dilator |
E1399 |
American Bidet Toilet Seat |
E1399 |
Aquamatic K-Thermia |
E0217, E0236, E0249 |
Diathermy Machines, Low frequency ultrasonic diathermy treatment device for home use, includes all components and accessories |
E0761, K1004, K1036 |
Hydrocollator Heating Unit |
E0225, E0239 |
Intermittent Traction Unit |
E1399 |
Paraffin Bath Units – non portable |
E1399 |
Parallel Bars |
E1399 |
Translift Chair |
E1399 |
The following items are considered non-reusable disposable supplies and are non-covered.
Description |
Code |
Disposable Sheets and Bags |
E1399 |
Delivery, Setup and Service A9901 is non-covered as this is included in the service.
Telephone Alert Systems, E1399 are considered emergency communications systems and do not serve a diagnostic or therapeutic purpose and are therefore non-covered.
Refer to Medical Policy Z-7 Electrical Nerve Stimulation for additional information.
Refer to Medical Policy E-32 Nebulizers for additional information.
Refer to Medical Policy E-52 Home Cervical Traction Therapy for additional information.
Refer to Medical Policy E-9 Non-Custom/Custom-Made Gradient Compression Garments/Stockings/Sleeves for additional information.
Refer to Medical Policy E-2 Home Dialysis Equipment and Supplies for additional information.
Refer to Medical Policy E-12 Beds- Accessories and Related Items for additional information.
Refer to Medical Policy O-27, Urological Supplies, for additional information.
Refer to Reimbursement Policy-070, Continuous Rental of Life Sustaining DME, for additional information.
Diagnosis Codes for Procedure Code E0117
G80.0 |
G80.1 |
G80.2 |
G80.4 |
G80.8 |
G80.9 |
G83.5 |
G83.81 |
G83.82 |
G83.83 |
G83.84 |
G83.89 |
Q05.0 |
Q05.1 |
Q05.2 |
Q05.3 |
Q05.4 |
Q05.5 |
Q05.6 |
Q05.7 |
Q05.8 |
Q05.9 |
Q07.00 |
Q07.01 |
Q07.02 |
Q07.03 |
S14.0XXA |
S14.0XXD |
S14.0XXS |
S14.101A |
S14.101D |
S14.101S |
S14.102A |
S14.102D |
S14.102S |
S14.103A |
S14.103D |
S14.103S |
S14.104A |
S14.104D |
S14.104S |
S14.105A |
S14.105D |
S14.105S |
S14.106A |
S14.106D |
S14.106S |
S14.107A |
S14.107D |
S14.107S |
S14.108A |
S14.108D |
S14.108S |
S14.109A |
S14.109D |
S14.109S |
S14.111A |
S14.111D |
S14.111S |
S14.112A |
S14.112D |
S14.112S |
S14.113A |
S14.113D |
S14.113S |
S14.114A |
S14.114D |
S14.114S |
S14.115A |
S14.115D |
S14.115S |
S14.116A |
S14.116D |
S14.116S |
S14.117A |
S14.117D |
S14.117S |
S14.118A |
S14.118D |
S14.118S |
S14.119A |
S14.119D |
S14.119S |
S14.121A |
S14.121D |
S14.121S |
S14.122A |
S14.122D |
S14.122S |
S14.123A |
S14.123D |
S14.123S |
S14.124A |
S14.124D |
S14.124S |
S14.125A |
S14.125D |
S14.125S |
S14.126A |
S14.126D |
S14.126S |
S14.127A |
S14.127D |
S14.127S |
S14.128A |
S14.128D |
S14.128S |
S14.129A |
S14.129D |
S14.129S |
S14.131A |
S14.131D |
S14.131S |
S14.132A |
S14.132D |
S14.132S |
S14.133A |
S14.133D |
S14.133S |
S14.134A |
S14.134D |
S14.134S |
S14.135A |
S14.135D |
S14.135S |
S14.136A |
S14.136D |
S14.136S |
S14.137A |
S14.137D |
S14.137S |
S14.138A |
S14.138D |
S14.138S |
S14.139A |
S14.139D |
S14.139S |
S14.141A |
S14.141D |
S14.141S |
S14.142A |
S14.142D |
S14.142S |
S14.143A |
S14.143D |
S14.143S |
S14.144A |
S14.144D |
S14.144S |
S14.145A |
S14.145D |
S14.145S |
S14.146A |
S14.146D |
S14.146S |
S14.147A |
S14.147D |
S14.147S |
S14.148A |
S14.148D |
S14.148S |
S14.149A |
S14.149D |
S14.149S |
S14.151A |
S14.151D |
S14.151S |
S14.152A |
S14.152D |
S14.152S |
S14.153A |
S14.153D |
S14.153S |
S14.154A |
S14.154D |
S14.154S |
S14.155A |
S14.155D |
S14.155S |
S14.156A |
S14.156D |
S14.156S |
S14.157A |
S14.157D |
S14.157S |
S14.158A |
S14.158D |
S14.158S |
S14.159A |
S14.159D |
S14.159S |
S24.0XXA |
S24.0XXD |
S24.0XXS |
S24.101A |
S24.101D |
S24.101S |
S24.102A |
S24.102D |
S24.102S |
S24.103A |
S24.103D |
S24.103S |
S24.104A |
S24.104D |
S24.104S |
S24.109A |
S24.109D |
S24.109S |
S24.111A |
S24.111D |
S24.111S |
S24.112A |
S24.112D |
S24.112S |
S24.113A |
S24.113D |
S24.113S |
S24.114A |
S24.114D |
S24.114S |
S24.119A |
S24.119D |
S24.119S |
S24.131A |
S24.131D |
S24.131S |
S24.132A |
S24.132D |
S24.132S |
S24.133A |
S24.133D |
S24.133S |
S24.134A |
S24.134D |
S24.134S |
S24.139A |
S24.139D |
S24.139S |
S24.141A |
S24.141D |
S24.141S |
S24.142A |
S24.142D |
S24.142S |
S24.143A |
S24.143D |
S24.143S |
S24.144A |
S24.144D |
S24.144S |
S24.149A |
S24.149D |
S24.149S |
S24.151A |
S24.151D |
S24.151S |
S24.152A |
S24.152D |
S24.152S |
S24.153A |
S24.153D |
S24.153S |
S24.154A |
S24.154D |
S24.154S |
S24.159A |
S24.159D |
S24.159S |
S34.01XA |
S34.01XD |
S34.01XS |
S34.02XA |
S34.02XD |
S34.02XS |
S34.101A |
S34.101D |
S34.101S |
S34.102A |
S34.102D |
S34.102S |
S34.103A |
S34.103D |
S34.103S |
S34.104A |
S34.104D |
S34.104S |
S34.105A |
S34.105D |
S34.105S |
S34.109A |
S34.109D |
S34.109S |
S34.111A |
S34.111D |
S34.111S |
S34.112A |
S34.112D |
S34.112S |
S34.113A |
S34.113D |
S34.113S |
S34.114A |
S34.114D |
S34.114S |
S34.115A |
S34.115D |
S34.115S |
S34.119A |
S34.119D |
S34.119S |
S34.121A |
S34.121D |
S34.121S |
S34.122A |
S34.122D |
S34.122S |
S34.123A |
S34.123D |
S34.123S |
S34.124A |
S34.124D |
S34.124S |
S34.125A |
S34.125D |
S34.125S |
S34.129A |
S34.129D |
S34.129S |
S34.131A |
S34.131D |
S34.131S |
S34.132A |
S34.132D |
S34.132S |
S34.139A |
S34.139D |
S34.139S |
S34.3XXA |
S34.3XXD |
S34.3XXS |
|
|
Diagnosis Codes for Procedure Codes A6410, A6411, A6412
H49.00 |
H49.01 |
H49.02 |
H49.03 |
H49.10 |
H49.11 |
H49.12 |
H49.13 |
H49.20 |
H49.21 |
H49.22 |
H49.23 |
H49.30 |
H49.31 |
H49.32 |
H49.33 |
H49.40 |
H49.41 |
H49.42 |
H49.43 |
H49.881 |
H49.882 |
H49.883 |
H49.889 |
H49.9 |
H50.00 |
H50.011 |
H50.012 |
H50.021 |
H50.022 |
H50.031 |
H50.032 |
H50.041 |
H50.042 |
H50.05 |
H50.06 |
H50.07 |
H50.08 |
H50.10 |
H50.111 |
H50.112 |
H50.121 |
H50.122 |
H50.131 |
H50.132 |
H50.141 |
H50.142 |
H50.15 |
H50.16 |
H50.17 |
H50.18 |
H50.60 |
H50.611 |
H50.612 |
H50.621 |
H50.622 |
H50.629 |
H50.631 |
H50.632 |
H50.639 |
H50.641 |
H50.642 |
H50.649 |
H50.651 |
H50.652 |
H50.659 |
H50.661 |
H50.662 |
H50.669 |
H50.671 |
H50.672 |
H50.679 |
H50.681 |
H50.682 |
H50.689 |
H50.69 |
H50.811 |
H50.812 |
H50.89 |
|
|
|
|
|
Diagnosis Codes for Procedure Code S8265
K08.8 |
M26.79 |
Q35.1 |
Q35.3 |
Q35.5 |
Q35.7 |
Q35.9 |
Q36.0 |
Q36.1 |
Q36.9 |
Q37.0 |
Q37.1 |
Q37.2 |
Q37.3 |
Q37.4 |
Q37.5 |
Q37.8 |
Q37.9 |
|
|
|
Diagnosis Codes for Procedure Code A4465, S8430, S8431
I89.0 |
I89.1 |
I89.8 |
I89.9 |
I97.2 |
Q82.0 |
Diagnosis Codes for Procedure Code E0637, E0638, E0641, E0642
G04.1 |
G35 |
G80.0 |
G80.1 |
G80.2 |
G80.3 |
G80.4 |
G80.8 |
G80.9 |
G82.20 |
G82.21 |
G82.22 |
G83.9 |
R25.0 |
R25.1 |
R25.2 |
R25.3 |
R25.8 |
R25.9 |
|
|
Diagnosis Codes for Procedure Code A4931, A4932
I12.0 |
I12.9 |
I13.0 |
I13.10 |
I13.11 |
I13.2 |
N18.1 |
N18.2 |
N18.30 |
N18.31 |
N18.32 |
N18.4 |
N18.5 |
N18.6 |
N18.9 |
N19 |
N99.0 |
|
|
|
|
Diagnosis Codes for Procedure Code E0480, E0481, E0484, S8185
E84.0 |
E84.8 |
E84.9 |
E84.11 |
E84.19 |
J41.0 |
J41.1 |
J41.8 |
J42 |
J44.0 |
J44.1 |
J44.9 |
J45.20 |
J45.21 |
J45.22 |
J45.30 |
J45.31 |
J45.32 |
J45.40 |
J45.41 |
J45.42 |
J45.50 |
J45.51 |
J45.52 |
J45.901 |
J45.902 |
J45.909 |
J45.990 |
J45.991 |
J45.998 |
J47.0 |
J47.1 |
J47.9 |
Q33.4 |
Z48.24 |
Z48.280 |
Z94.2 |
Z94.3 |
|
|
|
|
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.