HIGHMARK COMMERCIAL MEDICAL POLICY - PENNSYLVANIA

 
 
Section: Durable Medical Equipment
Number: E-38
Topic: Continuous Rental of Life Sustaining Durable Medical Equipment (DME)
Effective Date: April 1, 2005
Issued Date: April 4, 2005
Date Last Reviewed:

General Policy Guidelines

Indications and Limitations of Coverage

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.

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 E0445 E0450
E0460 E0461 E0463 E0464 E0471 E0472
E1390 E1391 K0671      

Traditional (UCR/Fee Schedule) Guidelines

FEP Guidelines

Comprehensive / Wraparound / PPO / Major Medical Guidelines

Any reference in this bulletin to non-billable services by a network provider may not be applicable to Major Medical.

Managed Care (HMO/POS) 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
E0445 Oximeter for measuring blood oxygen levels non-invasively
NOTE:
For eligibility guidelines for this device, see Medical Policy Bulletin E-25, Pulse Oximetry Device.
E0450 Volume control ventilator, without pressure support mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube)
E0460 Negative pressure ventilator; portable or stationary
E0461 Volume control ventilator, without pressure support mode, may include pressure control mode, used with non-invasive interface (e.g., mask)
E0463 Pressure support ventilator with volume control mode, may include pressure control mode, used with invasive interface (e.g., tracheostomy tube)
E0464 Pressure support ventilator with volume control mode, may include pressure control mode, used with non-invasive interface (e.g., mask)
E0471 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 E0471, see Medical Policy Bulletin E-34, Respiratory Assist Devices.
E0472 Respiratory assist device, bi-level pressure capability, 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 E0472, see Medical Policy Bulletin E-1, Durable Medical Equipment.
E1390 Oxygen concentrator, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate.
E1391 Oxygen concentrator, dual delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate, each
K0671

Portable oxygen concentrator, rental

NOTE:
For additional eligibility guidelines for procedure codes E1390, E1391, and K0671 see Medical Policy Bulletin E-11, Oxygen Concentrators and Related DME.

Text Attachment

Procedure Code Attachment


Glossary




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.