Durable Medical Equipment Reference List

The durable medical equipment (DME) list that follows is designed to facilitate the A/B MAC (HHH) and DME MACs processing of DME claims. This section is designed as a quick reference tool for determining the coverage status of certain pieces of DME and especially for those items commonly referred to by both brand and generic names. The information contained herein is applicable (where appropriate) to all DME national coverage determinations (NCDs) discussed in the DME portion of this manual. The list is organized into two columns. The first column lists alphabetically various generic categories of equipment on which NCDs have been made by the Centers for Medicare & Medicaid Services (CMS); the second column notes the coverage status.

In the case of equipment categories that have been determined by CMS to be covered under the DME benefit, the list outlines the conditions of coverage that must be met if payment is to be allowed for the rental or purchase of the DME by a particular patient, or cross-refers to another section of the manual where the applicable coverage criteria are described in more detail. With respect to equipment categories that cannot be covered as DME, the list includes a brief explanation of why the equipment is not covered. This DME list will be updated periodically to reflect any additional NCDs that CMS may make with regard to other categories of equipment.

When the A/B MAC (HHH) or DME MAC receives a claim for an item of equipment which does not appear to fall logically into any of the generic categories listed or has not been addressed in the processes outlined in regulations at 42 CFR §§414.114 and 414.240, the A/B MAC (HHH) or DME MAC has the authority and responsibility for deciding whether those items are covered under the DME benefit.

These decisions must be made by each A/B MAC (HHH) and DME MAC based on the advice of its medical consultants, taking into account:

• The Medicare Claims Processing Manual, Chapter 20, “Durable Medical Equipment Prosthetics and Orthotics, and Supplies (DMEPOS).”
• Whether the item has been approved for marketing by the Food and Drug Administration (FDA) and is otherwise generally considered to be safe and effective for the purpose intended; and
• Whether the item is reasonable and necessary for the individual patient.

The term DME is defined as equipment which, according to 42 CFR §414.202:

• Can withstand repeated use; i.e., could normally be rented and used by successive patients;
• Effective with respect to items classified as DME after January 1, 2012, has an expected life of at least 3 years;
• Is primarily and customarily used to serve a medical purpose;
• Generally, is not useful to a person in the absence of illness or injury; and,
• Is appropriate for use in a patient’s home.

Durable Medical Equipment Reference List

Cross-references: Medicare Benefit Policy Manual, Chapters 13, “Rural Health Clinic (RHC) and Federally Qualified Health Center (FQHC) Services,” 15, “Covered Medical and Other Health Services.”

Medicare Claims Processing Manual, Chapters 12, “Physician/Practitioner Billing,” 20, “Durable Medical Equipment, Prosthetics and Orthotics, and Supplies (DMEPOS),” 23, “Fee Schedule Administration and Coding Requirements.”

06/2005 - Covered mobility assistive equipment (MAE) for beneficiaries who have personal mobility deficit sufficient to impair performance of mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in customary locations in home. MAE includes canes, crutches, walkers, manual wheelchairs, power wheelchairs, and scooters. Effective date 5/06/2005. Implementation date 7/05/2005. (TN 37) (CR 3791)

11/2002 - Noncovered unsupervised home use of electrical stimulation for treatment of wounds not covered. Effective and implementation dates 04/01/2003. (TN 161) (CR 2313)

11/2000 - Changed benefit category and coverage status of augmentive and alternative communication devices. Fall within DME benefit category and covered if contractor's medical staff determines that patient's medical condition warrants device. Effective and implementation dates 01/01/2001. (TN 132) (CR 1328)

02/1999 - Clarified non-coverage policy for hypodermic jet pressure powered devices for the injection of insulin because of statute rather than effectiveness of device. Effective date NA.(TN 107)

07/1990 - Covered air-fluidized beds. Effective date (TN 44)

05/1989 - Added introduction to facilitate DME claims processing. Deleted references to manufacturers' brand and replaced with generic counterpart. Added statutory authorities for denial if authority other than 1862(a)(1). Added Blood Glucose Analyzer-Reflectance Colorimeter-deny as unsuitable for home use to list. Modified Communicator to specify that in addition to being a convenience item is not primarily medical in nature. Modified Heat and Massage Foam Cushion Pad-deny to specify as not primarily medical in nature; personal comfort item. Modified Injectors to specify that effectiveness not adequately demonstrated. Reorganized Iron Lung, Respirators and Ventilators to more accurately reflect current medical terminology but not affecting the coverage status. Effective date NA. (TN 36)

12/1986 - Covered continuous positive airway pressure. Effective date 01/12/1987. (TN 12)

09/1986 - Covered segmental therapy type lymphedema pump. Effective date 09/19/1986. (TN 9)