| Effective Date:05/01/2012 |
Title:Repair & Replacement of Durable Medical Equipment (DME)
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| Revision Date:08/01/2019
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Document:BI352:00
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| CPT Code(s):K0462; K0739-K0740; V5014; V5336; L4000; L4002; L4010; L4020; L4030; L4040; L4045; L4050; L4055; L4060; L4070; L4080; L4090; L4100; L4110; L4130; L4205; L4210; L7510; L7520
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Public Statement
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Effective Date:
a) This policy will apply to all services performed
on or after the above revision date which will become the new effective date.
b) For all services referred to
in this policy that were performed before the revision date, contact customer
service for the rules that would apply.
Repair of
durable medical equipment (DME) is covered when the patient owns the equipment
(rather than renting it), the damage was not caused by neglect or misuse, the
equipment is not currently covered by warranty, the repair is necessary to make
the equipment usable, and the cost of the repair does not exceed the cost of
purchasing a replacement piece of equipment.
Replacement of DME is covered when the patient owns the
equipment (rather than renting it), the equipment has been rendered unusable,
the damage was not caused by neglect or misuse, the equipment is not currently
covered by warranty, and the cost of repair exceeds the replacement cost.
Replacement of current DME due to end of warranty is not covered. Upgrading to
newer models with new functionality (irrespective of warranty) is not covered if
current DME is functional.
In general, repair and replacement of DME does not require prior
authorization. However, please refer to prior authorization list or specific
medical policies at QualChoice.com for items that require prior authorization.
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Medical Statement
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Limits
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Durable
medical equipment will not be replaced solely because a newer model is
available, even if the newer model has additional features desired by the
patient. Repair or replacement of DME is subject to plan limits; see your
Explanation of Coverage or Summary Plan Description.
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Reference
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Addendum:
1.
Effective
04/01/2017:
Emphasized expiration of warranty or upgrading to new DME with new features does
not qualify for coverage of DME replacement.
2.
Effective
06/01/2017:
added clarifying verbiage that requests for DME repair or replacement will need
to be submitted by ordering provider office along with provider’s clinic
progress notes. Requests from vendors or on vendor request forms will not be
accepted.
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Application to Products
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This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
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Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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