TITLE: DME (DURABLE MEDICAL EQUIPMENT) AND SUPPLIES
AUTHORITY: 38 CFR 17.270(a), 17.272(a) and 17.273(e)
RELATED AUTHORITY: 32 CFR 199.2 and 32 CFR 199.4(d)(3)(ii)
I. EFFECTIVE DATE
September 28, 1982
II. PROCEDURE CODE(S)
HCPCS Level II Codes: E0100-E2101, K0001-K0551, K0556-K0559, K0561-K0562, K0579, K0581-K0597
III. DEFINITIONS
A. DME (Durable Medical Equipment) is equipment which:
1. Is medically necessary for the treatment of a covered illness or injury.
2. Improves the function of a malformed, diseased, or injured body part, or delays further deterioration of a patient’s physical condition.
4. Is primarily and customarily used to serve a medical purpose, rather than primarily for transportation, comfort or convenience.
5. Provides the medically appropriate level of performance and quality for the medical condition present (that is, nonluxury and nondeluxe).
IV. POLICY
A. DME that is ordered as a medical necessity by a physician for the specific use of the beneficiary, and that complies with the applicable conditions, exceptions, limitations and exclusions of this manual is covered:
2-17.1-1
1. Preauthorization is required for any item purchased or rented with a total purchase price that exceeds $2,000.
B. The attending physician must prescribe equipment for a use consistent with required FDA (Food and Drug Administration) approved labeling for the item. When prescribed use of an item appears to be extraordinary, a signed statement from the manufacturer that a specific medical device is FDA approved for such a use is adequate evidence that the CHAMPVA requirement of FDA approval is met.
C. Repair of beneficiary owned DME, which otherwise meets the DME benefit requirement, is covered when necessary to make the equipment serviceable:
1. The repair charge may include the use of a temporary replacement item provided during the period of repair.
D. Replacement of beneficiary owned DME which otherwise meets the DME
benefit requirement, is allowed when the item is not serviceable due to normal wear, accidental damage, a change in the beneficiary's condition, or the device has been declared adulterated by the FDA. For life support equipment, a new item may be purchased when the same type of item in use is within 90-days of the manufacturers' recommended replacement threshold.
E. A wheelchair, or an approved alternative, which is necessary to provide basic
mobility is covered:
1. Medically necessary modifications may be considered for coverage.
2. A car lift for a wheelchair, or an approved alternative, is considered an accessory that may be considered for coverage.
F. Customization, accessories and supplies that are essential for beneficiary owned DME that otherwise meets the requirements to provide therapeutic benefit, or to assure the proper functioning of the equipment or to make the equipment serviceable is covered.
G. A duplicate item of DME, which otherwise meets the DME benefit requirement that is essential to provide a fail-safe, in-home, life-support system is covered.
H. A Sonicguide® device is authorized for a visually disabled helpless child.
V. POLICY CONSIDERATIONS
A. The maximum allowable amount for an item of durable medical equipment is:
1. The lower of the total rental cost for the period of medical necessity or the reasonable purchase cost (including purchase through VA sources).
2. Delivery charge, pick-up charge.
2-17.1-2
B. The reasonable purchase cost determination shall consider whether the item is new or used in the calculation of an allowable amount using allowable charge methodology for standard items of equipment, accessories and supplies within a state or purchased through VA sources, whichever is the lesser cost:
1. For customized items, the HAC (Health Administration Center) may price such items using documented evidence of retail prices for customization in the state of purchase or the price from VA procurement sources, whichever is the lesser cost.
2. Rental cost share associated with an initial prescription may be excluded from the calculation of the allowable amount for a second prescription that extends the period of medical necessity due to clinical complications.
C. The medically necessary period used in the rent or purchase allowable amount determination shall be the lesser of the estimated period of medical necessity or the period of continued eligibility.
D. Each initial claim must be documented by a prescription from the beneficiary's attending physician, dated within 30-days of the rental, order, purchase or repair of the equipment, which explains:
1. How the equipment is expected to contribute to the treatment of the beneficiary's specific illness or injury or to the reduction of the disabling effects of a malformed body member or developmental disability.
2. The beginning and ending dates of the period during which the DME will be medically necessary. An "indefinite" period of medical necessity is not an acceptable statement. A "lifetime" period of medical necessity is acceptable when supported in the statement of medical necessity.
E. A written notice to the beneficiary and to the equipment vendor shall be made when the HAC determines that:
1. Purchase is most advantageous to the government and the claim is for rental (the maximum allowable amount shall be specified in the notice).
2. Rental is most advantageous to the government and the claim is for purchase (the maximum allowable amount shall be specified in the notice).
F. Repair allowable amount is limited to the lower of the reasonable purchase cost or of the total rental cost for the remaining period of medical necessity.
G. Replacement equipment purchase allowable amount is limited to the reasonable purchase cost secured through VA procurement sources less any warranty credit or other payment due from third party liability.
H. A claim that is suspected to involve malicious damage, culpable neglect, or wrongful disposition of equipment shall be referred for program integrity review.
2-17.1-3
I. Coverage is provided for lifting chairs and/or seat lifts when prescribed by a physician for a patient with severe arthritis of the hip or knee and for patients with muscular dystrophy or other neuromuscular diseases when the patient can benefit therapeutically from use of such equipment. Coverage is subject to medical review.
J. Wheelchair or an approved alternative, which is medically necessary to provide basic mobility, is covered as DME including reasonable additional cost for medically necessary modifications to accommodate a particular disability, may be cost shared as DME.
VI EXCLUSIONS
A. DME for a beneficiary who is a patient in a type of facility that ordinarily provides the same type of items to its patients at no additional charge in the usual course of providing its services.
B. DME for which a beneficiary has no obligation to pay (DME received at no
charge from a Uniformed Services Medical Treatment Facility).
C. DME with deluxe, luxury or immaterial features that increase the cost of the item to the government relative to a similar item without those features.
D. Maintenance agreements.
E. Routine periodic servicing, such as testing, cleaning, regulating and checking
which the manufacturer does not require be performed by an authorized technician.
F. Rental or purchase of an allowed item, other than life-support equipment, solely to be used as a back-up to currently owned or rented equipment:
1. A cost that is non-advantageous to the government shall not be allowed
even when the equipment cannot be rented or purchased within a "reasonable distance" of the beneficiary's current address. The charge for delivery and pick-up is an allowable part of the cost of an item; consequently, distance does not limit access to equipment.
2. Line item interest and carrying charges for equipment purchase shall not be allowed. CHAMPVA lump-sum payment for purchase of an item of equipment is the limit of the government cost share liability. Interest and carrying charges result from an arrangement between the beneficiary and the equipment vendor for prorated payment of the beneficiary's cost share liability over time.
G. Vehicle lifts that are non-detachable and/or manufactured for a specific vehicle that cannot be removed from one vehicle and used in another vehicle are viewed as customizations to the vehicle and not an accessory to the wheelchair and are not covered.
2-17.1-4
H. Household chairs.
I. Recliner chair.
J. Spectacles, eyeglasses, contact lenses or other optical devices, and hearing aids.
K. Exercise equipment, spas, whirlpools, hot tubs, swimming pools
Question
Guest allan
TRANSMITTAL #: 95
DATE: 08/30/2006
TRICARE CHANGE #: N/A
CHAMPVA POLICY MANUAL
CHAPTER: 2
SECTION: 17.1
TITLE: DME (DURABLE MEDICAL EQUIPMENT) AND SUPPLIES
AUTHORITY: 38 CFR 17.270(a), 17.272(a) and 17.273(e)
RELATED AUTHORITY: 32 CFR 199.2 and 32 CFR 199.4(d)(3)(ii)
I. EFFECTIVE DATE
September 28, 1982
II. PROCEDURE CODE(S)
HCPCS Level II Codes: E0100-E2101, K0001-K0551, K0556-K0559, K0561-K0562, K0579, K0581-K0597
III. DEFINITIONS
A. DME (Durable Medical Equipment) is equipment which:
1. Is medically necessary for the treatment of a covered illness or injury.
2. Improves the function of a malformed, diseased, or injured body part, or delays further deterioration of a patient’s physical condition.
4. Is primarily and customarily used to serve a medical purpose, rather than primarily for transportation, comfort or convenience.
5. Provides the medically appropriate level of performance and quality for the medical condition present (that is, nonluxury and nondeluxe).
IV. POLICY
A. DME that is ordered as a medical necessity by a physician for the specific use of the beneficiary, and that complies with the applicable conditions, exceptions, limitations and exclusions of this manual is covered:
2-17.1-1
1. Preauthorization is required for any item purchased or rented with a total purchase price that exceeds $2,000.
B. The attending physician must prescribe equipment for a use consistent with required FDA (Food and Drug Administration) approved labeling for the item. When prescribed use of an item appears to be extraordinary, a signed statement from the manufacturer that a specific medical device is FDA approved for such a use is adequate evidence that the CHAMPVA requirement of FDA approval is met.
C. Repair of beneficiary owned DME, which otherwise meets the DME benefit requirement, is covered when necessary to make the equipment serviceable:
1. The repair charge may include the use of a temporary replacement item provided during the period of repair.
D. Replacement of beneficiary owned DME which otherwise meets the DME
benefit requirement, is allowed when the item is not serviceable due to normal wear, accidental damage, a change in the beneficiary's condition, or the device has been declared adulterated by the FDA. For life support equipment, a new item may be purchased when the same type of item in use is within 90-days of the manufacturers' recommended replacement threshold.
E. A wheelchair, or an approved alternative, which is necessary to provide basic
mobility is covered:
1. Medically necessary modifications may be considered for coverage.
2. A car lift for a wheelchair, or an approved alternative, is considered an accessory that may be considered for coverage.
F. Customization, accessories and supplies that are essential for beneficiary owned DME that otherwise meets the requirements to provide therapeutic benefit, or to assure the proper functioning of the equipment or to make the equipment serviceable is covered.
G. A duplicate item of DME, which otherwise meets the DME benefit requirement that is essential to provide a fail-safe, in-home, life-support system is covered.
H. A Sonicguide® device is authorized for a visually disabled helpless child.
V. POLICY CONSIDERATIONS
A. The maximum allowable amount for an item of durable medical equipment is:
1. The lower of the total rental cost for the period of medical necessity or the reasonable purchase cost (including purchase through VA sources).
2. Delivery charge, pick-up charge.
2-17.1-2
B. The reasonable purchase cost determination shall consider whether the item is new or used in the calculation of an allowable amount using allowable charge methodology for standard items of equipment, accessories and supplies within a state or purchased through VA sources, whichever is the lesser cost:
1. For customized items, the HAC (Health Administration Center) may price such items using documented evidence of retail prices for customization in the state of purchase or the price from VA procurement sources, whichever is the lesser cost.
2. Rental cost share associated with an initial prescription may be excluded from the calculation of the allowable amount for a second prescription that extends the period of medical necessity due to clinical complications.
C. The medically necessary period used in the rent or purchase allowable amount determination shall be the lesser of the estimated period of medical necessity or the period of continued eligibility.
D. Each initial claim must be documented by a prescription from the beneficiary's attending physician, dated within 30-days of the rental, order, purchase or repair of the equipment, which explains:
1. How the equipment is expected to contribute to the treatment of the beneficiary's specific illness or injury or to the reduction of the disabling effects of a malformed body member or developmental disability.
2. The beginning and ending dates of the period during which the DME will be medically necessary. An "indefinite" period of medical necessity is not an acceptable statement. A "lifetime" period of medical necessity is acceptable when supported in the statement of medical necessity.
E. A written notice to the beneficiary and to the equipment vendor shall be made when the HAC determines that:
1. Purchase is most advantageous to the government and the claim is for rental (the maximum allowable amount shall be specified in the notice).
2. Rental is most advantageous to the government and the claim is for purchase (the maximum allowable amount shall be specified in the notice).
F. Repair allowable amount is limited to the lower of the reasonable purchase cost or of the total rental cost for the remaining period of medical necessity.
G. Replacement equipment purchase allowable amount is limited to the reasonable purchase cost secured through VA procurement sources less any warranty credit or other payment due from third party liability.
H. A claim that is suspected to involve malicious damage, culpable neglect, or wrongful disposition of equipment shall be referred for program integrity review.
2-17.1-3
I. Coverage is provided for lifting chairs and/or seat lifts when prescribed by a physician for a patient with severe arthritis of the hip or knee and for patients with muscular dystrophy or other neuromuscular diseases when the patient can benefit therapeutically from use of such equipment. Coverage is subject to medical review.
J. Wheelchair or an approved alternative, which is medically necessary to provide basic mobility, is covered as DME including reasonable additional cost for medically necessary modifications to accommodate a particular disability, may be cost shared as DME.
VI EXCLUSIONS
A. DME for a beneficiary who is a patient in a type of facility that ordinarily provides the same type of items to its patients at no additional charge in the usual course of providing its services.
B. DME for which a beneficiary has no obligation to pay (DME received at no
charge from a Uniformed Services Medical Treatment Facility).
C. DME with deluxe, luxury or immaterial features that increase the cost of the item to the government relative to a similar item without those features.
D. Maintenance agreements.
E. Routine periodic servicing, such as testing, cleaning, regulating and checking
which the manufacturer does not require be performed by an authorized technician.
F. Rental or purchase of an allowed item, other than life-support equipment, solely to be used as a back-up to currently owned or rented equipment:
1. A cost that is non-advantageous to the government shall not be allowed
even when the equipment cannot be rented or purchased within a "reasonable distance" of the beneficiary's current address. The charge for delivery and pick-up is an allowable part of the cost of an item; consequently, distance does not limit access to equipment.
2. Line item interest and carrying charges for equipment purchase shall not be allowed. CHAMPVA lump-sum payment for purchase of an item of equipment is the limit of the government cost share liability. Interest and carrying charges result from an arrangement between the beneficiary and the equipment vendor for prorated payment of the beneficiary's cost share liability over time.
G. Vehicle lifts that are non-detachable and/or manufactured for a specific vehicle that cannot be removed from one vehicle and used in another vehicle are viewed as customizations to the vehicle and not an accessory to the wheelchair and are not covered.
2-17.1-4
H. Household chairs.
I. Recliner chair.
J. Spectacles, eyeglasses, contact lenses or other optical devices, and hearing aids.
K. Exercise equipment, spas, whirlpools, hot tubs, swimming pools
L. Hearing aids or other communication devices.
*END OF POLICY*
2-17.1-5
Source:
http://www.va.gov/hac/forbeneficiaries/champva/policymanual/cvapmchap2/1c2s17.1.pdf
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