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Policy No: 131

Originally Created: 02/01/2017

Section: Administrative

Last Reviewed: 03/01/2019

Last Revised: 03/01/2019

Approved: 03/07/2019

Effective: 04/01/2019

This policy does not apply to facilities (hospitals, surgery centers, kidney centers, etc....)

Definitions

Durable Medical Equipment (DME)

DME is equipment that:

  • Can withstand repeated use;
  • Is primarily and customarily used to serve a medical purpose;
  • Generally is not useful to a person in the absence of an illness or injury; and
  • Is appropriate for use in the home

All requirements of the definition must be met before an item can be considered to be durable medical equipment.

Policy Statement

DME claims must indicate whether the item(s) is rented or purchased. Purchased equipment must specify whether it is new or used.  If the claim does not indicated whether the item is new or used, the item may be denied for the appropriate modifier. The following table indicates the Healthcare Common Procedure Coding System (HCPCS) modifiers used to indicate status. Other modifiers may be used in addition to those listed below to increase specificity.

Modifer Status
LL Lease/rental (use when DME equipment rental is to be applied against the purchase price)
NR New when rented (use when an item that was new at the time of rental is subsequently purchased)
NU New equipment
RR Rental (use when DME is to be rented)
UE Used durable medical equipment

In addition to this policy, claims payments are subject to other plan requirements, including, but not limited to, requirements of medical necessity and reasonableness.

A DME item that has been purchased, may not be purchased or rented again within a 38-month period. Back-up, upgrade and replacement may be allowable as indicated on Clinical Position Statement – Durable Medical Equipment Upgrades, Replacements and Duplicates.

A DME item that has been categorized by Centers for Medicare & Medicaid Services (CMS) on the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule as a capped rental (CR) item will be considered purchased and owned by the member after 10 continuous rental months have been paid for the item. Rental charges received for the item after the 10th continuous month will be denied.

A DME item that has been categorized by CMS on the DMEPOS Fee Schedule as a Transcutaneous Electrical Nerve Stimulation (TE) item will be considered purchased and owned by the member after three (3) continuous months have been paid for the item. Charges received for the item after the 3rd continuous month will be denied.

References

Centers for Medicare & Medicaid Services (CMS), "Medicare Claims Processing Manual", Chapter 20, Sections 30.1.2, 30.5.2, 130.9

Centers for Medicare & Medicaid Services (CMS), "Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule"

Electronic Code of Federal Regulations, Title 42 "Public Health", Part 414 "Payment for Part B Medical and Other Health Services", Subpart B "Physicians and Other Practitioners", 414.202, 414.210, 414.229, 414.232

Cross References

CPS Dme 75 – Durable Medical Equipment Upgrades, Replacements and Duplicates

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.