E-38-001

HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

Section:	Durable Medical Equipment
Number:	E-38
Topic:	Continuous Rental of Life Sustaining Durable Medical Equipment (DME)
Effective Date:	July 1, 2002
Issued Date:	July 1, 2002
Date Last Reviewed:

General Policy Guidelines

While some items of durable medical equipment (DME) are for purchase only, numerous DME items can be rented or purchased. However, when an item of DME is rented, the total rental payments may not exceed the allowable purchase price of the item, unless the item has been identified as life sustaining DME. Life sustaining DME items can be continuously rented as long as the need exists for the equipment. For information on establishing the need for DME items see Medical Policy E-10, Certificate of Medical Necessity.

A list of items identified as life sustaining DME is in the Table Attachment below.

Coverage for DME is determined according to individual or group customer benefits.

Procedure Codes

E0194	E0431	E0434	E0439	E0450	E1390
K0533	K0534	S8105

Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

Comprehensive/Wraparound/PPO Guidelines

Refer to General Policy Guidelines

Managed Care (HMO/POS) Guidelines

Refer to General Policy Guidelines

Publications

References

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Table Attachment

Life Sustaining DME Items


E0194	Air fluidized bed Note: For additional eligibility guidelines for procedure code E0194, see Medical Policy Bulletin E-12, Beds-Accessories and Related Items.
E0431	Portable gaseous oxygen system, rental, includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing
E0434	Portable liquid oxygen system, rental, includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing
E0439	Stationary liquid oxygen system, rental, includes, container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0450	Volume ventilator, stationary or portable, with backup rate feature used with invasive interface (e.g., tracheostomy tube)
E1390	Oxygen concentrator, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate. Note: For additional eligibility guidelines for procedure code E1390, see Medical Policy Bulletin E-11, Oxygen Concentrators and Related DME.
K0533	Respiratory assist device, bi-level pressure capability, with backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) Note: For additional eligibility guidelines for procedure code K0533, see Medical Policy Bulletin E-34, Respiratory Assist Devices.
K0534	Respiratory assist device, bi-level pressure capacity, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device) Note: For additional eligibility guidelines for procedure code K0534, see Medical Policy Bulletin E-1, Durable Medical Equipment.
S8105	Oximeter for measuring blood oxygen levels non-invasively Note: Procedure S8105 is noncovered for most products. For eligibility guidelines for this device, see Medical Policy Bulletin E-25, Pulse Oximetry Device.

Text Attachment

Procedure Code Attachment

Glossary

Term	Description

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.