Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 05/01/2012 Title: Repair & Replacement of Durable Medical Equipment (DME)
Revision Date: 06/01/2017 Document: BI352:00
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
Public Statement

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.

The Pre-authorization requests for replacement or repair of orthotics require:

a)  Submission by the ordering provider office and not by the vendors AND

b)  Accompanying patient medical records such as provider clinic progress notes. Information submitted on vendor request forms is not acceptable.


Medical Statement

1)    Repair of durable medical equipment is covered when ALL of the following are met:

·        The patient owns the equipment; and

·        The required repairs are not the result of malicious damage, culpable neglect or misuse of the equipment; and

·        The expense of the repairs does not exceed the expense of purchasing a new piece of equipment; and

·        The equipment is not currently covered by warranty.

·        The repair is necessary to make the equipment usable.

NOTE:  Up to one month’s rental is covered for a replacement device to be used while a patient-owned DME is being repaired.  Payment will not exceed the rental allowance for the equipment that is being repaired.

 

2)    Replacement of durable medical equipment is covered when ALL of the following are met:

·       The equipment has become unusable; and

·       The patient owns the equipment; and

·       The required repairs are not the result of malicious damage, culpable neglect or misuse of the equipment; and

·       The expense of the repairs would exceed the expense of purchasing a new piece of equipment; and

3)    Replacement of durable medical equipment is NOT covered;

·       Simply because the warranty has expired

4)    To upgrade to newer models with new functionality (irrespective of warranty status)

 

 Codes Used In This BI:

 

K0462           Temporary replacement for patient-owned equipment being repaired, any type

K0739           Repair or non-routine service for DME other than oxygen equipment

                    requiring the skill of a technician, labor component

K0740           Repair or non-routine service for oxygen equipment requiring the skill of a

                    technician, labor component, per 15 minutes

V5014           Hearing aid repair/modifying

V5336           Repair communication device

L4000           Replace girdle for spinal orthotic (CTLSO or SO)

L4002           Replacement strap, any orthotic, includes all components

L4010           Replace trilateral socket brim

L4020           Replace quadrilateral socket brim, molded to patient model

L4030           Replace quadrilateral socket brim, custom fitted

L4040           Replace molded thigh lacer, for custom fabricated orthotic only

L4045           Replace non-molded thigh lacer, for custom fabricated orthotic only

L4050           Replace molded calf lacer, for custom fabricated orthotic only

L4055           Replace non-molded calf lacer, for custom fabricated orthotic only

L4060           Replace high roll cuff

L4070           Replace proximal and distal upright for KAFO

L4080           Replace metal bands KAFO, proximal thigh

L4090           Replace metal bands KAFO-AFO, calf or distal thigh

L4100           Replace leather cuff KAFO, proximal thigh

L4110           Replace leather cuff KAFO-AFO, calf or distal thigh

L4130           Replace pretibial shell

L4205           Repair of orthotic device, labor component, per 15 minutes

L4210           Repair of orthotic device, repair or replacement minor parts

L7510           Repair of prosthetic device, repair or replacement minor parts

L7520           Repair of prosthetic device, labor component, per 15 minutes


Limits

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.


Background

Durable Medical Equipment consists of items which:

 

    • are primarily and customarily used to serve a medical purpose;
    • are not useful to a person in the absence of illness or injury;
    • are ordered or prescribed by a physician;
    • are reusable; and
    • can stand repeated use.

Examples of DME include but are not limited to oxygen, wheelchairs, crutches, walkers, hospital beds, traction equipment, ventilators, monitors, lifts, and nebulizers.

  

DME may occasionally need repair to restore functioning after damage or from normal wear and tear of the device.

 

Equipment used for environmental control or to enhance the environmental setting or surroundings of an individual should not be considered durable medical equipment. Examples of these include air conditioners, air filters, humidifiers, etc.


Reference

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.


Application to Products
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.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.