Coverage Policies

Use the index below to search for coverage information on specific medical conditions.

Note: For Arkansas State or Public School employees, services subject to pre-authorization are managed by Active Health Management, as noted in their Summary Plan Description.

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Medical Providers: Payment for care or services is based on eligibility, medical necessity and available benefits at time of service and is subject to all contractual exclusions and limitations, including pre-existing conditions if applicable.

Future eligibility cannot be guaranteed and should be rechecked at time of service. Verify benefits by signing into My Account or calling Customer Service at 800.235.7111 or 501.228.7111.

If not specified in a QualChoice coverage policy (Benefit Interpretation), QualChoice follows care guidelines published by MCG Health.

QualChoice reserves the right to alter, amend, change or supplement medical policies as needed. QualChoice reviews and authorizes services and substances. CPT and HCPCS codes are listed as a convenience and any absent, new or changed codes do not alter the intent of the policy.

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: 08/01/2019 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.

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.


Medical Statement

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.