Durable medical equipment (DME) is a type of medical equipment that your doctor orders for medical reasons. Examples of DME are walkers, wheelchairs, and hospital beds. Show Equipment covered by Blue Shield Promise Cal MediConnect planCovered items include, but are not limited to:
We will pay for all medically necessary DME that Medicare and Medi-Cal usually pay for. If our supplier in your area does not carry a particular brand or maker, you may ask them if they can special-order it for you. In certain situations, Blue Shield Promise Cal MediConnect Plan may transfer ownership of DME to you depending on if you meet one or all of the following criteria:
In certain situations, we will transfer ownership of the DME item to you. Call Customer Care to find out about the requirements you must meet and the papers you need to provide. Plan coverage decisionIf you or your provider don’t agree with Blue Shield of California Promise Health Plan’s coverage decision, you, your representative, or your provider may file an appeal. You can also file an appeal if you don’t agree with your provider’s decision about what product or brand is appropriate for your medical condition. For more information about appeals, see Chapter 9 of your Member Handbook, which explains what to do if you have a problem or complaint. NOTE: Authorization rules for services may apply. For details, call Customer Care: Description:
Moreover, DME must meet the following definitions of "durable" AND "medical equipment":
Policy:
The information should include the individual's diagnosis and other pertinent functional information, including, but not limited to, duration of the individual's condition, clinical course (static, progressively worsening, or improving), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. Replacement Criteria for DME:
Requirements for DME Replacement:
Not Medically Necessary:
The use of athletic/exercise/physical fitness equipment (e.g., treadmills or stationary bicycles such as ROMTech PortableConnect Adaptive Technology with telehealth supplementation) as an adjunct to comprehensive rehabilitation and/or conventional physical therapy is not established as effective and would be considered NOT MEDICALLY NECESSARY. Reimbursement is to be limited to standard equipment. Note: to the extent a particular type of DME is considered not medically necessary or investigational and not medically necessary, it may be addressed in a specific Medical Policy or Clinical UM Guideline. BlueCross BlueShield of South Carolina will provide coverage for durable medical equipment when it is determined to be medically necessary. Coverage will be provided for repairs, parts and labor of eligible DME on an individual consideration basis when it is necessary to make the equipment usable. BlueCross BlueShield of South Carolina will review the option to rent or purchase eligible DME on an individual basis, based on specific contract verbiage. Rental or purchase of DME is paid only when the equipment has been delivered to the patient. Benefits are not reimbursed at the time the equipment is ordered. Reimbursement is limited to standard equipment. BlueCross BlueShield of South Carolina does not cover "deluxe" items. A deluxe item is any equipment with operating expenses, including supplies, that are in excess of the cost of the standard equipment meeting the medical necessity requirements of the plan.Reimbursement for maintenance agreements is the responsibility of the member and is not covered by BlueCross BlueShield of South Carolina. ****The below section will be effective on 01/01/2019**** Life Sustaining DME:
Payment is based on the monthly fee schedule amounts until medical necessity ends. No payment will be made for the purchase of equipment, maintenance and servicing, or for replacement of these items. Supplies and accessories are not allowed separately. ****The above section will be effective on 01/01/2019**** REIMBURSEMENT FOR BACKUP VENTILATORS
A backup ventilator may be placed in the patient’s home so that a patient is prepared for equipment failure, disconnects and power outages. Most ventilators operate on household electric current but can also be battery-operated. Some have internal batteries. A backup battery should be readily available in case of power outages. In some areas, a backup generator is also advisable. Repairs, parts and labor may be covered on an individual basis when it is necessary to make the equipment usable.
Replacement or repair of an item that has been misused or abused by the member or member's caregiver/family will be the responsibility of the member. Durable medical equipment will be considered "under warranty" for two years after initial rental or purchase. DME and prosthetics/orthotic fees include:
DME rental fees WILL COVER:
Education and training for patient and family are NOT ELIGIBLE for separate reimbursement. Durable medical equipment and services are not covered under the following criteria:
Rental versus purchase: When the DME is purchased, the total benefits available cannot exceed the contracted fee schedule. When the DME is rented, the benefits cannot exceed the total of the cost to purchase the equipment or the contracted fee schedule. Rental equipment that has reached a maximum reimbursement (rental paid up to the purchase price) will become the property of the member and will remain in the patient's possession. The DME provider may charge separately for supplies, as well as for repairs, parts and labor that are necessary for the function of the equipment. Equipment that is purchased without prior rental will be owned by the patient/member. Equipment Provided By a Physician's Office or Outpatient
Hospital: Compression stockings are considered MEDICALLY NECESSARY for the following conditions and/or complications:
**This applies only to pre-made or custom-made pressure gradient support stockings (e.g., Jobst, SigVarus, Venes, etc.) that have a pressure of 18 mm Hg or more, that require a physician's prescription, and that require measurements for fitting.** Typically, only one to two pair of stockings are necessary every three to six months. However, no more than eight pair per year will be reimbursed. Vascular Compression Units (VCU), utilized postoperatively for cold/compression therapy, as well as DVT and PE prevention, including, but not limited to, ThermoTek, VascuTherm 2, VascuTherm 3, ThermaCare, are considered NOT MEDICALLY NECESSARY. This health plan typically follows National and Local Medicare and DMERC policies, except where specifically addressed in the Policy Manual. Reimbursement for maintenance/service agreements is the responsibility of the member and is not a covered benefit. All DME is subject to medical necessity. Please see specific contract verbiage related to exclusions, limitations and precertification requirements. This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines. "Current Procedural Terminology © American Medical Association. All Rights Reserved" History From 2013 Forward
Is inogen covered by insurance?A: Yes, the Inogen One Oxygen Concentrator is covered by Medicare and many private insurance plans. Call today to see if you are eligible to receive the Inogen One at little to no additional cost (*co-payments and deductibles may apply).
Do all oxygen concentrators require a prescription?Oxygen concentrators are medical devices required to be sold and used only with a prescription. You should not use an oxygen concentrator at home unless it has been prescribed by a health care provider. Giving yourself oxygen without talking to a doctor first may do more harm than good.
How many hours do portable oxygen concentrators last?Depending on the brand and unit, you may expect portable oxygen concentrators to operate for up to four or five hours on a single battery charge, with a maximum of 13 hours for double battery units. However, POC with a continuous flow setting can provide oxygen 24 hours a day once charged.
Do portable oxygen concentrators run out of oxygen?An oxygen concentrator can provide an endless supply of oxygen as long as it has power. An oxygen concentrator requires power via a charged battery or access to a power outlet to function. An oxygen concentrator uses the surrounding air to produce supplemental oxygen, so it never needs to be refilled.
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