Durable medical equipment

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Durable Medical Equipment (DME) is any equipment that provides therapeutic benefits to a patient in need because of certain medical conditions and/or illnesses. Durable Medical Equipment (DME) 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, disability, or injury;
  • are ordered or prescribed by a physician;
  • are reusable;
  • can stand repeated use, and
  • are appropriate for use in the home.[1]

DME includes, but is not limited to, wheelchairs (manual and electric), traction equipment, canes, crutches, walkers, kidney machines, ventilators, oxygen, monitors, pressure mattresses, lifts, nebulizers, bili blankets and bili lights.

Similar criteria are used by Medicare[2] and Medicaid.[3]

(n) The term "durable medical equipment" - DME - includes, but is not limited to, wheelchairs (manual and electric), hospital beds, traction equipment, canes, crutches, walkers, kidney machines, ventilators, oxygen, monitors, pressure mattresses, lifts, nebulizers, bili blankets and bili lights.

Insurance companies will provide coverage for Durable Medical Equipment when it is determined to be medically necessary because the medical criteria and guidelines for its use are met.

Durable medical equipment may be covered when All of the following criteria are met:

  • 1. The equipment provides therapeutic benefit to a patient in need because of certain medical conditions and/or illnesses; And
  • 2. The DME is prescribed by a licensed provider; And
  • 3. The DME does not serve primarily as a comfort or convenience item; And
  • 4. The equipment does not have significant non-medical uses (e.g., environmental control equipment, air conditioners, air filters, and humidifiers).

Durable Medical Equipment and Services are not covered when..

  • The DME add-ons or upgrades are intended primarily for convenience or upgrades beyond what is necessary to meet the member’s legitimate medical needs. Examples include: decorative items, unique materials (e.g. magnesium wheelchairs wheels, lights, extra batteries, etc.)*; or
  • When it does not provide a therapeutic benefit to a patient in need because of certain medical conditions or illnesses; or
  • When the DME has not been prescribed by a licensed provider; or
  • When the DME serves primarily as a comfort or convenience item. Trays, back packs, wheelchair racing equipment are examples of non-covered or convenience items*; or
  • When the equipment is used in a facility that is expected to provide such items to the patient; or
  • When the devices and equipment are used to enhance the environmental setting (for example; air conditioners, humidifiers, air filters, portable Jacuzzi pumps, or chair lifts used to go up and down the stairs). These are not primarily medical in nature and will not be eligible for coverage*; or
  • For equipment delivery services and set-up, education and training for patient and family, and nursing visits, are not eligible for separate reimbursement regardless of agreement to rent or purchase.
  • For DME add-ons or upgrades that are intended primarily for member/caregiver convenience, or that do not significantly enhance DME functionality.*

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