The term durable medical equipment (DME) is defined as equipment which, according to 42 CFR §414.202:

• Can withstand repeated use; i.e., could normally be rented and used by successive members; and
• Effective with respect to items classified as DME after January 1, 2012, has an expected life of at least 3 years; and
• Is primarily and customarily used to serve a medical purpose; and
• Generally, is not useful to a member in the absence of illness or injury; and
• Is appropriate for use in a member’s home.

To view specific LCD and NCD information, as well as other CMS sources, please refer to the LINKS section at the bottom of this policy page.

The DME list that follows is designed to facilitate the processing of DME claims. This section is designed as a quick reference tool for determining the coverage status of certain pieces of DME and especially for those items commonly referred to by both brand and generic names.

In the case of equipment categories that have been determined by CMS to be covered under the DME benefit, the list outlines the conditions of coverage that must be met if payment is to be allowed for the rental or purchase of the DME by a particular member, or cross-refers to another policy where the applicable coverage criteria are described in more detail. With respect to equipment categories that cannot be covered as DME, the list includes a brief explanation of why the equipment is not covered.

When a claim is received for an item of equipment which does not appear to fall logically into any of the generic categories listed or has not been addressed in the processes outlined in regulations at 42 CFR §§414.114 and 414.240, Medicare Advantage has the authority and responsibility for deciding whether those items are covered under the DME benefit.

These decisions must be made based on the advice of the medical consultants, taking into account:

• The Medicare Claims Processing Manual, Chapter 20, "Durable Medical Equipment Prosthetics and Orthotics, and Supplies (DMEPOS)."
• Whether the item has been approved for marketing by the Food and Drug Administration (FDA) and is otherwise generally considered to be safe and effective for the purpose intended; and
• Whether the item is medically necessary for the member.
  

The following items may be considered medically necessary when criteria are met; if criteria are not met, the items will deny not medically necessary:

• Air-Fluidized Beds
• Alternating Pressure Pads, Mattresses and Lamb's Wool Pads
  • If member has, or is highly susceptible to, decubitus ulcers and the member’s physician specifies that he/she has specified that he will be supervising the course of treatment.
• Audible/Visible Signal/Pacemaker Monitors (See Self-Contained Pacemaker Monitors)
• Bead Beds
• Bed Pans (autoclavable - hospital type)
  • If member is bed confined.
• Bed Side Rails (See Hospital Beds)
• Blood Glucose Monitors
  • If member meets certain conditions.
• Canes
  • If member meets Mobility Assistive Equipment (MAE) clinical criteria.
• Commodes
  • If member is confined to bed or room.
    • The term "room confined" means that the member's condition is such that leaving the room is medically contraindicated.
• Communications (See Speech Generating Devices)
• Continuous Passive Motion Devices 
  • Members who have received a total knee replacement.
  • Use of device must commence within two (2) days following surgery.
  • Coverage is limited to that portion of the three (3)-week period following surgery during which the device is used in the member’s home.
  • There is insufficient evidence to justify coverage of these devices for longer periods of time or for other applications.
• Continuous Positive Airway Pressure (CPAP) Devices
• Crutches
  • If member meets MAE clinical criteria.
• Cushion Lift Power Seats (See Seat Lifts)
• Digital Electronic Pacemaker Monitors (See Self-Contained Pacemaker Monitors)
• Electric Hospital Beds (See Hospital Beds)
• Face Masks (Oxygen)
  • If oxygen is covered.
• Flow Meters (See Medical Oxygen Regulators)
• Fluidic Breathing Assistors (See Intermittent Positive Pressure Breathing Machines)
• Fomentation Devices (See Heating Pads)
• Gel Flotation Pads and Mattresses (See Alternating Pressure Pads and Mattresses)
• Grab Bars
  • Safety items; and
  • Limited to any combination of these items;
  • Eligible for replacement every three (3) years. 
• Heating Pads
  • If member’s medical condition is one for which the application of heat in the form of a heating pad is therapeutically effective.
• Heat Lamps
  • If member's medical condition is one for which the application of heat in the form of a heat lamp is therapeutically effective.
• Hospital Beds
• Hot Packs (See Heating Pads)
• Humidifiers (Oxygen) (See Oxygen Humidifiers)
• Hydraulic Lifts (See Patient Lifts)
• Infusion Pumps
  • For external and implantable pumps.
• Intermittent Positive Pressure Breathing Machines 
  • If a member’s ability to breathe is severely impaired.
• Iron Lung (See Ventilators)
• Lamb’s Wool Pads (See Alternating Pressure Pads, Mattresses)
• Lymphedema Pumps (See Pneumatic Compression Device)
• Mattresses
  • Only when hospital bed is medically necessary.
• Medical Oxygen Regulators
  • If member’s ability to breathe is severely impaired.
• Mobile Geriatric Chairs
  • If member meets MAE clinical criteria (See Rolling Chairs)
• Motorized Wheelchairs
  • If member meets MAE clinical criteria.
• Muscle Stimulators
  • For certain conditions.
• Nebulizers
  • If members ability to breathe is severely impaired.
• Oxygen
  • If the oxygen has been prescribed for used in connection with medically necessary DME.
• Oxygen Humidifiers
  • If the oxygen has been prescribed for used in connection with medically necessary DME.
• Oxygen Regulators (Medical) (See Medical Oxygen Regulators)
• Oxygen Tents
• Paraffin Bath Units (Portable) (See Portable Parrafin Bath Units)
• Patient Lifts
  • If member’s condition is such that periodic movements is necessary to effect improvement or to arrest/retard deterioration condition.
• Percussors
  • For mobilizing respiratory tract secretions in members with chronic obstructive lung disease, chronic bronchitis, or emphysema;
  • When member or operator of powered percussor receives appropriate training by a physician or therapist; and
  • No one competent to administer manual therapy is available.
• Portable Oxygen Systems (Regulated)
  • Regulated Covered (adjustable covered under conditions specified in a flow rate).  
  • Preset Deny - (flow rate Deny - emergency, first-aid, or not adjustable) precautionary equipment; essentially not therapeutic in nature.
• Portable Paraffin Bath Units
  • When the member has undergone a successful trial period of paraffin therapy ordered by a physician; and
  • The member’s condition is expected to be relieved by long term use of this modality.
• Postural Drainage Boards
  • If member has a chronic pulmonary condition.
• Quad-Canes
  • If member meets MAE clinical criteria.
• Respirators (See Ventilators)
• Rolling Chairs
  • Covered if member meets MAE clinical criteria.
  • Coverage is limited to those roll-about chairs having casters of at least five (5) inches in diameter and specifically designed to meet the needs of ill, injured, or otherwise impaired members.
  • Coverage is denied for the wide range of chairs with smaller casters as are found in general use in homes, offices, and institutions for many purposes not related to the care/treatment of ill/injured members. 
• Safety Rollers
  • If member meets MAE clinical criteria.
• Seat Elevation Equipment (power-operated) on Medicare Advantage Covered Power Wheelchairs
  • Covered under certain conditions
• Seat Lifts
  • Covered under certain conditions.
• Self-Contained Pacemaker Monitors
  • When prescribed by a physician for a member with a cardiac pacemaker.
• Sitz Baths
  • If medical staff determines member has an infection or injury of the perineal area; and
  • The item has been prescribed by the member’s physician as a part of his planned regimen of treatment in the member’s home.
• Steam Packs (See Heating Pads)
• Suction Machines
  • If medical staff determines that the machine specified in the claim is medically required and appropriate for home use without technical or professional supervision.
• Traction Equipment
  • If member has orthopedic impairment requiring traction equipment which prevents ambulation during the period of use.
• Trapeze Bars
  • If member is bed confined and the member needs a trapeze bar to sit up because of respiratory conditions, to change body position for other medical reasons, or to get in and out of bed.
• Tub/Shower Chairs
  • Limit one (1) every three (3) years
    
• Tub Stools or Benches
  • Limit one (1) every three (3) years
    
• Tub Transfer Benches
  • Limit one (1) every three (3) years
    
• Ultraviolet Cabinets
  • For selected members with generalized intractable psoriasis;
  • Using appropriate consultation, it should be determined whether medical and other factors justify treatment at home rather than at alternative sites, e.g., outpatient department of a hospital.
• Urinals (Autoclavable)
  • If member is bed confined (hospital type).
• Vaporizer
  • If member has a respiratory illness.
• Ventilators
  • For treatment of:
    • Neuromuscular diseases; or
    • Thoracic restrictive diseases; or
    • Chronic respiratory failure consequent to chronic obstructive pulmonary disease (COPD). Includes both positive and negative pressure types.
• Walkers
  • If member meets MAE clinical criteria.
• Water and Pressure Pads and Mattresses (See Alternating Pressure Pads, Mattressed and Lambs Wool Pads)
• Wheelchairs (Manual)
  • If member meets MAE clinical criteria.
• Wheelchairs (power operated)
  • If member meets MAE clinical criteria.
• Wheelchairs (scooter/POV)
  • If member meets MAE clinical criteria.
• Wheelchairs (specially-sized)
  • If member meets MAE clinical criteria.
• Whirlpool Bath Equipment  
  • If a member is homebound; and
  • Has a (standard) condition for which the whirlpool bath can be expected to provide substantial therapeutic benefit justifying its cost.
  • Where member is not homebound but has such a condition, payment is restricted to the cost of providing the services elsewhere; e.g., an outpatient department of a participating hospital, if that alternative is less costly.
  • In all cases, refer claim to medical staff for a determination.

The following items do not meet the definition of DME because they are considered COMFORT OR CONVENIENCE items; and not primarily medical in nature, and will deny non-covered:

• Bathtub Lifts
  
• Beds-Lounges (Power or Manual)
• Carafes
• Elevators
• Emesis Basins
• Heat and Massage Foam Cushion Pads
• Injectors (hypodermic jet)
• Massage Devices
• Over-bed Tables
• Portable Whirlpool Pumps
• Raised Toilet Seats
• Sauna Baths
• Spare Tanks of Oxygen
• Stairway Elevators (See Elevators)
• Standing Tables
• Telephone Alert Systems
  • Emergency communication systems.
  • Do not serve a diagnostic or therapeutic purpose.
• Whirlpool Pumps (See Portable Whirlpool Pumps)
• White Canes

The following items do not meet the definition of DME because they are considered ENVIRONMENTAL CONTROL EQUIPMENT; and not primarily medical in nature, and will deny non-covered:

• Air Cleaners
  
• Air Conditioners
• Dehumidifiers (Room or Central Heating System Type)
• Electric Air Cleaners
• Electrostatic Machines
• Heating and Cooling Plants
• Humidifiers (Room or Central Heating System Types)
• Portable Room Heaters
• Preset Portable Oxygen Units

The following items do not meet the definition of DME because they are considered INAPPROPRIATE FOR HOME USE; and will deny non-covered:

• Beds (Oscillating) - Institutional Equipment
• Blood Glucose Analyzers (Reflectance Colorimeter)
• Diathermy Machines (Standard Pulses Wave Types)
• Electrical Stimulation for Wounds
• Esophageal Dilators
• Paraffin Bath Units (Standard)
• Parallel Bars - Institutional Equipment
• Pulse Tachometers
  • Not medically necessary for monitoring pulse of homebound member with/without a cardiac pacemaker
• Reflectance Colorimeters (See Blood Glucose Analyzers)

The following items do not meet the definition of DME because they are considered NONREUSABLE SUPPLY; and not a rental type item, and will deny non-covered:

• Catheters
  
• Disposable Sheets and Bags
• Elastic Stockings
• Face Masks (Surgical)
• Incontinent Pads
• Irrigating Kits
• Leotards/ Pressure Leotards
• Pressure Leotards
• Support Hose/ Fabric Supports
• Surgical Leggings

The following items do not meet the definition of DME because they are considered NOT PRIMARILY MEDICAL IN NATURE; and not rental type item, and will deny non-covered:

• Augmentative Communication Devices (See Speech Generating Devices)
  
• Bed Baths (Home type) - Hygienic Equipment
• Bed Lifters (Bed Elevators)
• Bed Boards
• Bidet Toilet Seats (See Toilet Seats)
• Braille Teaching Texts - Educational Equipment
• Communicators (See Speech Generating Devices)
• Exercise Equipment
• Speech Teaching Machines - Educational Equipment
• Toilet Seats
• Treadmill Exercisers