Medical Policy Original Effective Date: 05-22-06

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

Disclaimer Refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans or the plan may have broader or more limited benefits than those listed in these criteria.

Description This Medical Policy includes the following items: I. Automatic External Defibrillator

II. Sphygnomanometers (Electronic Blood Pressure Monitor) Systems

III. Bright Light Therapy for Seasonal Affective Disorder (SAD)

IV. Compression Hose:

V. Hospital Grade Breast Pump:

VI. Enuresis Alarms

VII. Erectile Dysfunction Devices

VIII. Hearing Aids:

IX. Home PT/INR Monitoring

X. Pelvic Floor Electrical Stimulation for Urinary Incontinence

XI. Other covered DME for Centennial members

Non-Covered Services:

Coverage Determination Durable Medical Equipment (DME) listed in PHP’s Medical Policies may or may not require Prior Authorization. Log on to Pres Online to submit a request: https://ds.phs.org/preslogin/index.jsp

• Items that do not require Prior Authorization are subject to retrospective review, and are only covered for the indications listed.

• All Durable Medical Equipment is subject to the limitations and exclusions of the member’s specific benefit plan

Items classified in DME may not be covered in every instance. Coverage is subject to the following:

• The equipment must be necessary and reasonable for the treatment of an illness or injury, or to improve the functioning of a body part.

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

• The patient’s diagnosis justifies that the equipment or supply being requested is medically necessary.

• The practitioner’s documentation must include the patient’s diagnosis, the reason equipment is required and the practitioner’s estimate of the duration of its need.

Durable Medical Equipment (DME) is equipment which: • Can withstand repeated use

• Is primarily and customarily used to serve a medical purpose

• Generally, is not useful to a person in the absence of illness or injury

• Is appropriate for use in a patient’s home, at school or at work

• DME can be rented or purchased, depending on the length of time the member will need the equipment, or if there must be frequent and substantial servicing in order to avoid risk to the patient’s health. The decision whether to rent or purchase DME is made by PHP.

Many of the following criteria refer the user to CMS and New Mexico HSD (NMAC Program Rules) for both covered and non-covered DME. Medicare has contracted with CGS to process Durable Medical Equipment, Prosthetic, Orthotic and Supply (DMEPOS) claims for Jurisdiction C. This responsibility includes the development of Local Coverage Determinations (coverage policies), which has additional specific criteria not listed in this Medical Policy. To verify covered DME click one of the following web links:

1. Direct link to CGS homepage for a complete listing of Local Coverage Determination. These LCDs are listed alphabetically along with the HCPCS codes.

2. To verify if a particular DME is covered, access Official Medicare Durable Medical Equipment Coverage, Official U.S. Government Site for Medicare

To verify non-covered DME click the following:

• Alphabetical list of non-covered (see Attachment A) Durable Medical Equipment Reference List NCD (280.1).

Other criteria that rule DME for covered/non-covered Durable Medical Equipment, NM Medicaid Centennial Care.

• New Mexico Covered/Non-Covered Durable Medical Equipment, NMAC Number 8.324.5

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

o 8.324.5.12 Covered Services: (See A-D for listings) o 8.324.5.13 Utilization Review and Prior Authorization:

See section D: Prior Authorization for specific services (1-3) for listings. -

o 8.324.5.15 Non Covered Services

o New Mexico, Non-covered Durable Medical Equipment, NMAC Number 8.301.3.15

I. Automatic External Defibrillator: Automatic external defibrillator is used for patients at high risk of sudden cardiac death due to cardiac arrhythmia. PHP follows CMS Celerian Group Company (CGS), J-C DME MAC guidelines in the coverage of automatic external defibrillators, (DME MAC LCD L33690), and for ICD-10 listing see Local Coverage Article (A52458). A. A wearable defibrillator (K0606) is covered for

beneficiaries if they meet one of the criteria (1-4), described below:

1. A documented episode of ventricular fibrillation or a sustained, lasting 30 seconds or longer, ventricular tachyarrhythmia. These dysrhythmias may be either spontaneous or induced during an electrophysiologic (EP) study, but may not be due to a transient or reversible cause and not occur during the first 48 hours of an acute myocardial infarction; or

2. Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrhythmia such as long QT syndrome or hypertrophic cardiomyopathy; or

3. Either documented prior myocardial infarction or dilated cardiomyopathy and a measured left ventricular ejection fraction less than or equal to 0.35; or

4. A previously implanted defibrillator now requires explanatation.

B. A non-wearable automatic defibrillator (E0617) is covered for beneficiaries in two circumstances. They meet either (1) both criteria A and B or (2) criteria C, described below: 1. The beneficiary has one of the following conditions

(1-8): a) A documented episode of cardiac arrest due to

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

ventricular fibrillation, not due to a transient or reversible cause

b) A sustained, lasting 30 seconds or longer, ventricular tachyarrhythmia, either spontaneous or induced during an electrophysiologic (EP) study, not associated with acute myocardial infarction, and not due to a transient or reversible cause

c) Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrythmias such as long QT syndrome or hypertrophic cardiomyopathy

d) Coronary artery disease with a documented prior myocardial infarction with a measured left ventricular ejection fraction less than or equal to 0.35, and inducible, sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) during an EP study. To meet this criterion; (1) The myocardial infarction must have

occurred more than 4 weeks prior to the external defibrillator prescription; and,

(2) The EP test must have been performed more than 4 weeks after the qualifying myocardial infarction.

e) Documented prior myocardial infarction and a measured left ventricular ejection fraction less than or equal to 30%. Beneficiaries must not have: (1) Cardiogenic shock or symptomatic

hypotension while in a stable baseline rhythm; or,

(2) Had a coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) within past 3 months; or,

(3) Had an enzyme-positive MI within past month; or,

(4) Clinical symptoms or findings that would make them a candidate for coronary revascularization; or,

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(5) Irreversible brain damage from preexisting cerebral disease; or,

(6) Any disease, other than cardiac disease (e.g. cancer, uremia, liver failure), associated with a likelihood of survival less than one year.

f) Beneficiaries with ischemic dilated cardiomyopathy (IDCM), documented prior myocardial infarction (MI), New York Heart Association (NYHA) Class II and III heart failure, and measured left ventricular ejection fraction (LVEF) ≤ 35%.

g) Beneficiaries with nonischemic dilated cardiomyopathy (NIDCM) > 3 months, NYHA Class II and III heart failure, and measured LVEF ≤ 35%

h) Beneficiaries who meet one of the previous criteria (1-7) and have NYHA Class IV heart failure

2. Implantation surgery is contraindicated 3. A previously implanted defibrillator now requires

explantation

II. Sphygnomanometers (Electronic Blood Pressure Monitor) Systems: A. PHP follows NMAC 8.324.5.13 covers the benefit for

Centennial Care beneficiaries with prior authorization for a non-institutionalized recipient for electronic monitoring devices, such as electronic sphygmomanometers, oxygen saturation, fetal or blood glucose monitors and pacemaker monitors. The recommended HCPCS codes are: (A4660, A4663 and A4670), respectively.

B. Covered for patients with end stage renal disease or hypertension (essential or labile).

III. Bright Light Therapy for Seasonal Affective Disorder (SAD) in adults:

A. Bright light therapy may be indicated for SAD when the patient meets criteria for a major depressive disorder with seasonal specifiers.

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

IV. Compression Hose: Only covered for Centennial members [8.324.5.12] with prior authorization Covered for members 21 years and older meeting medically necessity to aide in mobility, support or physical function. . Limited to stockings that are custom-fabricated/custom-fitted compression stockings, (A6530 – A6544).

V. Hospital Grade Breast Pump: A. Hospital Grade breast pumps are considered non-

standard and require prior authorization. A hospital grade pump is designed for use in the hospital and occasionally for home use based on medical necessity. Hospital Grade breast pumps (HCPCS code E0604) are approved for rental only. An in-network provider, such as the mother’s attending obstetrician, midwife or primary care practitioners, or the infant’s practitioner, must order the device. Indications for hospital grade breast pump include: 1. Ineffective breast feeding:

a) Inability of infant to latch on and effectively breastfeed due to the following conditions: 1) Prematurity- defined as 24-36 weeks of

gestation 2) Newborn feeding difficulties caused by

conditions such as jaundice 3) Genetic disorders (e.g., Down’s Syndrome) 4) Neurological disorders (e.g., hydrocephalus) 5) Congenital anomalies (e.g., cleft palate);

b) Pump will be approved until infant reaches 40 weeks gestational age or is discharged.

c) Mothers and Infants who continue to require a medical need for the pump will be approved for four months.

d) Any extension of time will require medical records review.

2. Separation of mother and infant: Pump may be

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

authorized for infants meeting the above medical criteria for the following reasons: a) Infant hospitalized (i.e., NICU, Pediatrics) b) Mother hospitalized (i.e., infection, surgery) c) Authorization will be given for an initial period of 4

weeks. All requests for extension of time will require medical records review.

VI. Enuresis Alarms: All of the following criteria must be met:

1. Member is at least five years of age, and has a diagnosis of nocturnal enuresis (ICD-10: N39.44, F98.0).

2. History and physical exam are negative for a specific etiology.

3. Alarm to be used in conjunction with supportive measures, which may include but are not limited to education, fluid restriction and night awakening. (HCPCS Codes are S8270 & E0740)

VII. Erectile Dysfunction Devices. Vacuum erection devices are covered when medically necessary and only when pharmacologic treatment is inappropriate. Refer to the member’s GSA and CMS NCD (230.4), for Diagnosis and Treatment of Impotence.

VIII. Hearing Aids:

For Bone-Anchored Hearing Aid (BAHA), see separate Medical Policy, MPM 2.9. Please refer to the member’s specific benefit plan to determine coverage. Hearing Aids only covered for Centennial members [NMAC 8.324.6], prior authorization is required. Current NMAC Title 8 Social Services, Chapter 324 Adjunct Services, Part 5 Vision Appliances, Hearing Appliances, Durable Medical Equipment, Oxygen, Medical Supplies, Prosthetics and orthotics. For details of coverage, available on the Internet at. 8.324.5.12.B Hearing appliances: NMAC 8.324.5. A. Hearing appliances:

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

1. Within specified limitations, MAD covers the following services when furnished by primary care provider (PCP), licensed audiologists or by licensed hearing aid dealers: a. hearing aid purchase, rental repairs, hearing aid

repair and handling, replacements, and the loan of equipment while repairs or replacements are made: (i) binaural hearing aid fitting will be covered for a

MAP eligible recipient with bilateral hearing loss who is attending an educational institution, seeking employment, is employed, or for a MAP eligible recipient with a current history of binaural fitting; or

(ii) binaural hearing aid fitting will be considered on a case-by-case basis for a MAP eligible recipient determined to be legally blind;

b. hearing aid accessories and supplies, including the batteries required after the initial supply furnished at the time the hearing aid is dispensed; and

c. Mandatory purchase of hearing aid insurance against loss and breakage, up to four years for all purchased hearing aids for Salud members

• hearing aid insurance against loss and breakage for up to four years for all purchased hearing aids; hearing aid insurance is required when the aid is dispensed; four years of hearing aid insurance is required for: (i) a MAP eligible recipient under 21 years of age; (ii) a MAP eligible recipient residing in a nursing

facility (NF); or (iii) a MAP eligible recipient who has a developmental or intellectual disability; 8.324.5 NMAC 5

d. replacement of hearing aids is limited to the provisions of the MAP eligible recipient’s hearing aid insurance; the provider is responsible for obtaining insurance for every hearing aid purchased for a MAP eligible recipient.

Hearing appliances: Hearing aid selection and fitting is considered included in the hearing aid dispensing fee, and will not be reimbursed separately B. Presbyterian Senior Care (HMO) Plan coverage of hearing

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aids: Hearing aids or examination for the purpose of prescribing, fitting or changing hearing aids is not a covered benefit for Medicare members. Certain devices that produce perception of sound by replacing the function of the middle ear, cochlea or auditory nerve are payable by Medicare as prosthetic devices. These devices are indicated only when hearing aids are medically inappropriate or cannot be utilized due to congenital malformation, chronic disease, severe sensorineural hearing loss or surgery. The following are prosthetic devices: 1. Cochlear implants and auditory brainstem implants. 2. Osseointegrated implants.

C. Group health coverage* for hearing aids: Hearing aids and the evaluation for the fitting of hearing aids are not covered except for school-aged children under 18 years old (or under 21 years if still attending high school). Coverage includes: 1. Up to $2,200.00 every 36 months “per hearing-impaired

ear” for school-aged children under 18 years old (or under 21 years if still attending high school).

2. Fitting and dispensing services, including ear molds as necessary to maintain optimal fit, as provided by a participating provider licensed in New Mexico.

Group health coverage, per Senate Bill 529, includes any form of self-insurance that is offered, issued or renewed under the Health Care Purchasing Act.

IX. Home PT/INR Monitoring: Test materials and equipment.

Patients must meet CMS coverage criteria for home INR monitoring. Refer to CMS NCD 190.11 Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring for Anticoagulation Management (190.11) for diagnostic coverage and additional requirement. As of January 1, 2019 the following listed ICD-10 are not covered, CMS Pub 100-20, Transmittal 2138. Warfarin (also prescribed under other trade names, e.g., Coumadin®) is a self-administered, oral anticoagulant (blood thinner) medication that affects the vitamin K-dependent clotting factors. It has a narrow therapeutic index and must be closely monitored to avoid serious complications. A PT/INR monitoring system is a portable testing device that includes a finger-stick and an FDA-cleared meter that measures the time it takes for a person’s blood plasma to clot.

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Indications and Limitations of Coverage: Medicare will cover for the use of home PT/INR monitoring for chronic, oral anticoagulation management for patients with mechanical heart valves, chronic atrial fibrillation, or venous thromboembolism (inclusive of deep venous thrombosis and pulmonary embolism) on warfarin. The monitor and the home testing must be prescribed by a treating physician as provided at 42 CFR 410.32(a), and all of the following requirements must be met:

1. The patient must have been anticoagulated for at least 3 months prior to use of the home INR device; and,

2. The patient must undergo a face-to-face educational program on anticoagulation management and must have demonstrated the correct use of the device prior to its use in the home; and,

3. The patient continues to correctly use the device in the context of the management of the anticoagulation therapy following the initiation of home monitoring; and,

4. Self-testing with the device should not occur more frequently than once a week

X. Pelvic Floor Electrical Stimulation for Urinary Incontinence: Pelvic floor electrical stimulation involves the use of a non-implantable pelvic floor electrical stimulators (E0740), which is often a vaginal or anal probe, and an external pulse generator that delivers variable rates of current through the pelvic floor. The goal is to stimulate the nerves involved in bladder and sphincter function and to strengthen pelvic floor musculature to decrease or eliminate urge, stress and mixed forms of urinary incontinence. A failed trial of PME training is defined as no clinically significant improvement in urinary continence after completing 4 weeks of an ordered plan of pelvic muscle exercises designed to increase periurethral muscle strength. PHP follows the CMS National Coverage Determination for Non-Implantable Pelvic Floor Electrical Stimulator (230.8). The methods of pelvic floor electrical stimulation vary in location, stimulus frequency (Hz), stimulus intensity or amplitude (mA), pulse duration (duty cycle), treatments per day, number of treatment days per week, length of time for each treatment

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session, overall time period for device use and between clinic and home settings. In general, the stimulus frequency and other parameters are chosen based on the patient's clinical diagnosis. Indications and Limitations of Coverage: Pelvic floor electrical stimulation with a non-implantable stimulator is covered for the treatment of stress and/or urge urinary incontinence in cognitively intact patients who have failed a documented trial of pelvic muscle exercise (PME) training.

XI. Other covered DME for Centennial members (8.324.5 – Durable Medical Equipment). Prior Authorization is required

• Disposable gloves (sterile or non-sterile) are limited to 200 per month.

• Disposable diapers or underpads for recipient age three years and older who suffers from neurological or neuromuscular disorders or who has other diseases associated with incontinence is limited to either 200 diapers per month or 150 underpads per month

• Bathtub rails and other rails for use in the bathroom.

• Hospital bed and full length side rails.

• Wheelchair tray.

• For patients who require enteral nutritional supplements and products (must be tube fed), requests should be submitted directly to Presbyterian Health Plan’s enteral nutrition provider.

Exclusions Non-Covered Services: Those non-covered services that are not listed in this section. Please visit the following sites for more details on those non-covered services. • For NMAC Non-Covered Durable Medical Equipment and

Medical Supplies see NM Administrative Code number 8.301.3. • CMS NCD (280.1) Item/Service Description: National Coverage

Determination (ND) for Durable Medical Equipment Reference List (280.1).

1. Protective clothing or materials. • Window tinting • Light filters • Screens

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

• Specialized clothing 2. Hygiene and miscellaneous products.

• Oral moisturizing swabs (example: Toothettes®) • Antimicrobial hand gel (example: Prevacare™) • Incontinence wipes • Control III disinfectant • Cotton tip applicators, sterile or non-sterile • Dressing supplies in the absence of an open wound

3. Wigs. (A9282) are not a covered benefit for Salud or Medicare Commercial member contracts vary and most contracts exclude wigs from coverage, even when there is a medical reason for the hair loss. Refer to the member’s specific benefit plan to determine coverage.

4. Assistive Listening Devices (AKA FM Systems). Public school systems are required to provide FM systems for educational purposes for students starting at age 3.

5. Comfort and convenience items are not covered. Please refer to criteria in 8.301.3.15 NMAC for DME or medical supplies that are not covered. This includes, but is not limited to the following: • Incontinence supplies, single-use disposable sheets. • Items hygienic in nature, such as bath/shower chairs, bath

systems. • Shower/tub bench. • Toilet frame. • Raised toilet seat. **See also items that do not meet the CMS definition of Durable Medical Equipment (DME). See Attachment A Reference list located at the end of the policy pages.

6. Upgraded or deluxe items, or duplicate items (i.e., for home, office or car)

Definitions Durable Medical Equipment (DME): Items that are reusable and provide support for physical limitations and disabilities can withstand repeated use and are used for a medical purpose, in the member’s residence (excluding a SNF or acute care hospital) under a physician’s supervision. Items requiring frequent and substantial servicing (rental only): Items for which there must be frequent and substantial servicing in order to avoid risk to the patient’s health. Examples of these items

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

include ventilators, aspirators, IPPB machines, passive motion exercise devices, etc. Items in this category may be rented for as long as the patient’s need continues. Reasonable Useful Lifetime: In the absence of Medicare Program Instructions, the Reasonable Useful Lifetime can be determined by the member’s individual plan, but in no case can it be less than 5 years. Computation of the useful lifetime is based on when the equipment was delivered to the member, not the age of the equipment. If the equipment remains in good working order and meets the member’s medical needs, it should not be automatically replaced. Standard Documentation Requirements: Please review Local Coverage Article DME MACs (A55426).

REASONABLE AND NECESSARY CRITERIA (R&N)

MEDICAL RECORD DOCUMENTATION

CONTINUED MEDICAL NEED

CONTINUED USE

REFILL DOCUMENTATION

Coding The coding listed in this Medical Policy is for reference only. Covered and non-covered DME are within this list. See CMS Local Coverage Determinations (LCDs) for additional coding references.

HCPCS Codes for Automatic External Defibrillators

HCPCS Codes Automatic External Defibrillators A9999 Miscellaneous DME supply or accessory, not otherwise

specified E0617 External defibrillator with integrated electrocardiogram analysis

K0606 Automatic external defibrillator, with integrated electrocardiogram analysis, garment type

K0607 Replacement battery for automated external defibrillator, garment type only, each

K0608 Replacement garment for use with automated external defibrillator, each

K0609 Replacement electrodes for use with automated external defibrillator, garment type only, each

ICD-10 for Automatic External Defibrillators HCPCS Code E0617

ICD-10 CODE ICD-10 for HCPCS Code E0617 I21.01 ST elevation (STEMI) myocardial infarction involving left main

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

ICD-10 CODE ICD-10 for HCPCS Code E0617 coronary artery

I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery

I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall

I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery

I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall

I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery

I21.29 ST elevation (STEMI) myocardial infarction involving other sites

I21.3 ST elevation (STEMI) myocardial infarction of unspecified site I21.4 Non-ST elevation (NSTEMI) myocardial infarction

I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall

I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall

I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction

I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites

I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site

I25.2 Old myocardial infarction I42.1 Obstructive hypertrophic cardiomyopathy I42.2 Other hypertrophic cardiomyopathy I45.81 Long QT syndrome I46.2 Cardiac arrest due to underlying cardiac condition I46.8 Cardiac arrest due to other underlying condition I46.9 Cardiac arrest, cause unspecified I47.0 Re-entry ventricular arrhythmia I47.2 Ventricular tachycardia I49.01 Ventricular fibrillation I49.02 Ventricular flutter

T82.110A Breakdown (mechanical) of cardiac electrode, initial encounter

T82.111A Breakdown (mechanical) of cardiac pulse generator (battery), initial encounter

T82.118A Breakdown (mechanical) of other cardiac electronic device, initial encounter

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ICD-10 CODE ICD-10 for HCPCS Code E0617

T82.119A Breakdown (mechanical) of unspecified cardiac electronic device, initial encounter

T82.120A Displacement of cardiac electrode, initial encounter

T82.121A Displacement of cardiac pulse generator (battery), initial encounter

T82.128A Displacement of other cardiac electronic device, initial encounter

T82.129A Displacement of unspecified cardiac electronic device, initial encounter

T82.190A Other mechanical complication of cardiac electrode, initial encounter

T82.191A Other mechanical complication of cardiac pulse generator (battery), initial encounter

T82.198A Other mechanical complication of other cardiac electronic device, initial encounter

T82.199A Other mechanical complication of unspecified cardiac device, initial encounter

T82.6XXA Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter

T82.7XXA Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter

ICD-10 for Automatic External Defibrillators HCPCS Code K0606, K0607, K0608 & K0609

ICD-10 CODE For HCPCS K0606-K0609, Automatic External Defibrillators

A18.84 Tuberculosis of heart

I21.01 ST elevation (STEMI) myocardial infarction involving left main coronary artery

I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery

I21.09 ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall

I21.11 ST elevation (STEMI) myocardial infarction involving right coronary artery

I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall

I21.21 ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery

I21.29 ST elevation (STEMI) myocardial infarction involving other sites

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ICD-10 CODE For HCPCS K0606-K0609, Automatic External Defibrillators

I21.3 ST elevation (STEMI) myocardial infarction of unspecified site I21.4 Non-ST elevation (NSTEMI) myocardial infarction

I22.0 Subsequent ST elevation (STEMI) myocardial infarction of anterior wall

I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall

I22.2 Subsequent non-ST elevation (NSTEMI) myocardial infarction

I22.8 Subsequent ST elevation (STEMI) myocardial infarction of other sites

I22.9 Subsequent ST elevation (STEMI) myocardial infarction of unspecified site

I25.2 Old myocardial infarction I42.0 Dilated cardiomyopathy I42.1 Obstructive hypertrophic cardiomyopathy I42.2 Other hypertrophic cardiomyopathy I42.3 Endomyocardial (eosinophilic) disease I42.4 Endocardial fibroelastosis I42.5 Other restrictive cardiomyopathy I42.6 Alcoholic cardiomyopathy I42.7 Cardiomyopathy due to drug and external agent I42.8 Other cardiomyopathies I42.9 Cardiomyopathy, unspecified I43 Cardiomyopathy in diseases classified elsewhere

I45.81 Long QT syndrome I46.2 Cardiac arrest due to underlying cardiac condition I46.8 Cardiac arrest due to other underlying condition I46.9 Cardiac arrest, cause unspecified I47.0 Re-entry ventricular arrhythmia I47.2 Ventricular tachycardia I49.01 Ventricular fibrillation I49.02 Ventricular flutter

T82.110A Breakdown (mechanical) of cardiac electrode, initial encounter

T82.111A Breakdown (mechanical) of cardiac pulse generator (battery), initial encounter

T82.118A Breakdown (mechanical) of other cardiac electronic device, initial encounter

T82.119A Breakdown (mechanical) of unspecified cardiac electronic device, initial encounter

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ICD-10 CODE For HCPCS K0606-K0609, Automatic External Defibrillators

T82.120A Displacement of cardiac electrode, initial encounter

T82.121A Displacement of cardiac pulse generator (battery), initial encounter

T82.128A Displacement of other cardiac electronic device, initial encounter

T82.129A Displacement of unspecified cardiac electronic device, initial encounter

T82.190A Other mechanical complication of cardiac electrode, initial encounter

T82.191A Other mechanical complication of cardiac pulse generator (battery), initial encounter

T82.198A Other mechanical complication of other cardiac electronic device, initial encounter

T82.199A Other mechanical complication of unspecified cardiac device, initial encounter

T82.6XXA Infection and inflammatory reaction due to cardiac valve prosthesis, initial encounter

T82.7XXA Infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter

HCPCS Codes for Blood Pressure Monitor Systems

HCPCS Code HCPCS Codes for Blood Pressure Monitor Systems

A4660 Sphygmomanometer/blood pressure apparatus with cuff and stethoscope

A4663 Blood pressure cuff only A4670 Automatic blood pressure monitor

CPT for Seasonal Affective Disorder (SAD) in adults

Code CPT for Seasonal Affective Disorder (SAD) in adults: 96900 Actinotherapy (ultraviolet light)

HCPCS for Seasonal Affective Disorder (SAD) in adults

HCPCS codes HCPCS for Seasonal Affective Disorder (SAD) in adults A4634 Replacement bulb for therapeutic light box, tabletop model E0203 Therapeutic lightbox, minimum 10,000 lux, table top mode

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Covered ICD-10 for Seasonal Affective Disorder (SAD) in adults

ICD-10 codes Covered ICD-10 for Seasonal Affective Disorder (SAD) F30.10 Manic episode without psychotic symptoms, unspecified F30.11 Manic episode without psychotic symptoms, mild F30.12 Manic episode without psychotic symptoms, moderate F30.13 Manic episode without psychotic symptoms, Severe F30.2 Manic episode, severe with psychotic symptoms F30.3 Manic episode in partial remission F30.4 Manic episode in full remission F30.8 Other manic episodes F30.9 Manic episode, unspecified F33.0 Major depressive disorder, recurrent, mild F33.1 Major depressive disorder, recurrent, moderate

F33.2 Major depressive disorder, recurrent severe without psychotic features

F33.3 Major depressive disorder, recurrent, severe with psychotic symptoms

F33.40 Major depressive disorder, recurrent, in remission, unspecified F33.41 Major depressive disorder, recurrent, in partial remission F33.42 Major depressive disorder, recurrent, in Full remission F33.8 Other recurrent depressive disorders F33.9 Major depressive disorder, recurrent, unspecified

Covered HCPCS Code per Medicare for Gradient Compression Stockings used for Open Venous Stasis Ulcer

HCPCS Description A6531 Gradient compression stocking, below knee, 30-40 mmHg, each A6532 Gradient compression stocking, below knee, 40-50 mmHg, each

A6545 Gradient compression wrap, non-elastic, below knee, 30-50 mm hg, each

HCPCS Codes for Graduated Compression Stockings (Hose)

HCPCS Graduated Compression Stockings (Hose) Description

Those marked with an * are covered services for Wounds only Others without * are for non-wound services

A6530 Gradient compression stocking, below knee, 18-30 mmHg, each

*A6531 Gradient compression stocking, below knee, 30-40 mmHg, each (*wound only)

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HCPCS Graduated Compression Stockings (Hose) Description

Those marked with an * are covered services for Wounds only Others without * are for non-wound services

*A6532 Gradient compression stocking, below knee, 40-50 mmHg, each (*wound only)

A6533 Gradient compression stocking, thigh length, 18-30 mmHg, each A6534 Gradient compression stocking, thigh length, 30-40 mmHg, each

*A6535 Gradient compression stocking, thigh length, 40-50 mmHg, each (*wound only)

A6536 Gradient compression stocking, full length/chap style, 18-30 mmHg, each

A6537 Gradient compression stocking, full length/chap style, 30-40 mmHg, each

A6538 Gradient compression stocking, full length/chap style, 40-50 mmHg, each

A6539 Gradient compression stocking, waist length, 18-30 mmHg, each A6540 Gradient compression stocking, waist length, 30-40 mmHg, each A6541 Gradient compression stocking, waist length, 40-50 mmHg, each A6544 Gradient compression stocking, garter belt A6549 Gradient compression stocking/sleeve

ICD-10 for Graduated Compression Stockings (Hose) for non-wound diagnosis

ICD-10 Gradient Compression Stockings (Hose) for non-wound related diagnoses

I80.00 Phlebitis and thrombophlebitis of superficial vessels of unspecified lower extremity

I80.10 Phlebitis and thrombophlebitis of unspecified femoral vein

I80.209 Phlebitis and thrombophlebitis of unspecified deep vessels of unspecified lower extremity

I80.3 Phlebitis and thrombophlebitis of lower extremities, unspecified I80.219 Phlebitis and thrombophlebitis of unspecified iliac vein

I82.409 Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity

I81.419, Acute embolism and thrombosis of unspecified femoral vein I82.429 Acute embolism and thrombosis of unspecified iliac vein I82.439 Acute embolism and thrombosis of unspecified popliteal vein

I82.4Y9 Acute embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity

I82.449 Acute embolism and thrombosis of unspecified tibial vein

I82.499 Acute embolism and thrombosis of other specified deep vein of unspecified lower extremity

I82.4Z9 Acute embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity

I82.509 Chronic embolism and thrombosis o

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ICD-10 Gradient Compression Stockings (Hose) for non-wound related diagnoses f unspecified deep veins of unspecified lower extremity

I82.599 Chronic embolism and thrombosis of other specified deep vein of unspecified lower extremity

I82.519 Chronic embolism and thrombosis of unspecified femoral vein I82.529 Chronic embolism and thrombosis of unspecified iliac vein I82.539 Chronic embolism and thrombosis of unspecified popliteal vein

I82.5Y9 Chronic embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity

I82.549 Chronic embolism and thrombosis of unspecified tibial vein

I82.5Z9 Chronic embolism and thrombosis of unspecified deep veins of unspecified distal lower extremity

I82.819 Embolism and thrombosis of superficial veins of unspecified lower extremities

I83.009 Varicose veins of unspecified lower extremity with ulcer of unspecified site

I83.019 Varicose veins of right lower extremity with ulcer of unspecified site I83.029 Varicose veins of left lower extremity with ulcer of unspecified site

I83.209 Varicose veins of unspecified lower extremity with both ulcer of unspecified site and inflammation

I97.2 Postmastectomy lymphedema syndrome I89.0 Lymphedema, not elsewhere classified I95.1 Orthostatic hypotension I87.2 Venous insufficiency (chronic) (peripheral)

O22.20 Superficial thrombophlebitis in pregnancy, unspecified trimester O22.21 Superficial thrombophlebitis in pregnancy, first trimester O22.22 Superficial thrombophlebitis in pregnancy, second trimester O22.23 Superficial thrombophlebitis in pregnancy, third trimester O87.0 Superficial thrombophlebitis in the puerperium O22.21 Superficial thrombophlebitis in pregnancy, first trimester O22.22 Superficial thrombophlebitis in pregnancy, second trimester O22.23 Superficial thrombophlebitis in pregnancy, third trimester O87.0 Superficial thrombophlebitis in the puerperium O22.30 Deep phlebothrombosis in pregnancy, unspecified trimester O22.31 Deep phlebothrombosis in pregnancy, first trimester O22.32 Deep phlebothrombosis in pregnancy, second trimester O22.33 Deep phlebothrombosis in pregnancy, third trimester O22.31 Deep phlebothrombosis in pregnancy, first trimester O22.32 Deep phlebothrombosis in pregnancy, second trimester O22.33 Deep phlebothrombosis in pregnancy, third trimester O87.1 Deep phlebothrombosis in the puerperium O87.1 Deep phlebothrombosis in the puerperium O87.1 Deep phlebothrombosis in the puerperium

HCPCS for Breast Pump

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HCPCS Codes Description: HCPCS for Breast PUMP

E0602 Breast pump, manual, any type E0603 Breast pump, electric (AC and/or DC), any type

A4281 Tubing for breast pump, replacement A4282 Adapter for breast pump, replacement

A4284 Breast shield and splash protector for use with breast pump, replacement

A4285 Polycarbonate bottle for use with breast pump, replacement A4286 Locking ring for breast pump, replacement

ICD-10 for Breast Pump

ICD-10 codes Description: ICD-10 for Breast PUMP O00.00 - O9A.53 Complications of pregnancy, childbirth and the puerperium

Q35.1 - Q37.9 Cleft palate and cleft lip

Q38.0 - Q38.4, Q38.6 - Q38.8

Other congenital malformations of tongue, mouth and pharynx

Z34.00 - Z34.93 Encounter for supervision of normal pregnancy

Z39.0 - Z39.2 Encounter for maternal postpartum care and examination

HCPCS codes for Home PT/INR Monitoring for Anticoagulation Management HCPCS codes PT/INR Monitoring (G0248, G0249 & G0250)

G0248

Demonstration, prior to initial use, of home INR monitoring for patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria, under the direction of a physician; includes: face-to-face demonstration of use and care of the INR monitor, obtaining at least one blood sample, provision of instructions for reporting home INR test results, and documentation of patient ability to perform testing and report results.

G0249

Provision of test materials and equipment for home INR monitoring of patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; includes provision of materials for use in the home and reporting of test results to physician; testing not occurring more frequently than once a

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HCPCS codes PT/INR Monitoring (G0248, G0249 & G0250)

week; testing materials, billing units of service include 4 tests

G0250

Physician review, interpretation, and patient management of home INR testing for a patient with either mechanical heart valve(s), chronic atrial fibrillation, or venous thromboembolism who meets Medicare coverage criteria; testing not occurring more frequently than once a week; billing units of service include 4 tests

ICD-10 for Home PT/INR per CMS Manual, Pub 100-20. (These codes are not covered as of January 1, 2019)

ICD-10 for Home PT/INR for HCPCS code G0248, G0249 I80.01 Phlebitis and thrombophlebitis of superficial vessels of right

lower extremity

I80.02 Phlebitis and thrombophlebitis of superficial vessels of left lower extremity

I80.03 Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral

I80.201 Phlebitis and thrombophlebitis of unspecified deep vessels of right lower extremity

I80.202 Phlebitis and thrombophlebitis of unspecified deep vessels of left lower extremity

I80.203 Phlebitis and thrombophlebitis of unspecified deep vessels of lower extremities, bilateral

I80.8 Phlebitis and thrombophlebitis of other sites I82.1 Thrombophlebitis migrans

I82.401 Acute embolism and thrombosis of unspecified deep veins of right lower extremity

I82.402 A cute embolism and thrombosis of unspecified deep veins of left lower extremity

I82.403 Acute embolism and thrombosis of unspecified deep veins of lower extremity, bilateral

I82.4Y1 Acute embolism and thrombosis of unspecified deep veins of right proximal lower extremity

I82.4Y2 Acute embolism and thrombosis of unspecified deep veins of left proximal lower extremity

I82.4Y3 Acute embolism and thrombosis of unspecified deep veins of proximal lower extremity, bilateral

I82.4Z1 Acute embolism and thrombosis of unspecified deep veins of right distal lower extremity

I82.4Z2 Acute embolism and thrombosis of unspecified deep veins of left distal lower extremity

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ICD-10 for Home PT/INR for HCPCS code G0248, G0249 I82.4Z3 Acute embolism and thrombosis of unspecified deep veins of

distal lower extremity, bilateral

I82.501 Chronic embolism and thrombosis of unspecified deep veins of right lower extremity

I82.502 Chronic embolism and thrombosis of unspecified deep veins of left lower extremity

I82.503 Chronic embolism and thrombosis of unspecified deep veins of lower extremity, bilateral

I82.5Y1 Chronic embolism and thrombosis of unspecified deep veins of right proximal lower extremity

I82.5Y2 Chronic embolism and thrombosis of unspecified deep veins of left proximal lower extremity

I82.5Y3 Chronic embolism and thrombosis of unspecified deep veins of proximal lower extremity, bilateral

I82.5Z1 Chronic embolism and thrombosis of unspecified deep veins of right distal lower extremity

I82.5Z2 Chronic embolism and thrombosis of unspecified deep veins of left distal lower extremity

I82.5Z3 Chronic embolism and thrombosis of unspecified deep veins of distal lower extremity, bilateral

I82.601 Acute embolism and thrombosis of unspecified veins of right upper extremity

I82.602 Acute embolism and thrombosis of unspecified veins of left upper extremity

I82.603 Acute embolism and thrombosis of unspecified veins of upper extremity, bilateral

I82.611 Acute embolism and thrombosis of superficial veins of right upper extremity

I82.612 Acute embolism and thrombosis of superficial veins of left upper extremity

I82.613 Acute embolism and thrombosis of superficial veins of upper extremity, bilateral

I82.701 Chronic embolism and thrombosis of unspecified veins of right upper extremity

I82.702 Chronic embolism and thrombosis of unspecified veins of left upper extremity

I82.703 Chronic embolism and thrombosis of unspecified veins of upper extremity, bilateral

I82.711 Chronic embolism and thrombosis of superficial veins of right upper extremity

I82.712 Chronic embolism and thrombosis of superficial veins of left upper extremity

I82.713 Chronic embolism and thrombosis of superficial veins of upper extremity, bilateral

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ICD-10 for Home PT/INR for HCPCS code G0248, G0249 I82.811 Embolism and thrombosis of superficial veins of right lower

extremity

I82.812 Embolism and thrombosis of superficial veins of left lower extremity

I82.813 Embolism and thrombosis of superficial veins of lower extremities, bilateral

O22.51 Cerebral venous thrombosis in pregnancy, first trimester O22.52 Cerebral venous thrombosis in pregnancy, second trimester O22.53 Cerebral venous thrombosis in pregnancy, third trimester Z95.4 Presence of other heart-valve replacement

HCPCS code for Pelvic Floor Electrical Stimulation HCPCS Code Description

E0740 Non-implanted pelvic floor electrical stimulator, complete system

ICD-10 Codes Diagnosis for Pelvic Floor Electrical Stimulation (E0740)

N39.3 Stess Incontinence (female) (male)

N39.41 Urge incontinence

N39.42 Incontinence without sensory awareness

N39.43 Post-void dribbling

N39.44 Nocturnal enuresis

N39.45 Continuous leakage

N39.46 Mixed incontinence

N39.490 Other specified urinary incontinence, over flow incontinence

N39.491 Coital incontinence

N39.492 Postural (urinary) incontinence

N39.498 Other specified urinary incontinence

N39.8 Other specified d/o of urinary system

N39.9 Disorder of urinary system, uspecified

R32 Unspecified urinary incontinence

References: 1. New Mexico Human Services Department, Medical Assistance Division Program Policy Manual NMAC 8.324.5, Vision Appliances,

Medical Policy Original Effective Date: 05-22-06

Revised Date: 03-27-2019 Page 25 of 34

Durable Medical Equipment (DME): Miscellaneous MPM 4.5 Hearing Appliances, Durable Medical Equipment, Oxygen,Medical

Supplies,Prosthetics and Orthotics. , Effective Date: January 01, 2014. Accessed 08/20/2018

2. Celerian Group Company (CGS), Government Services. Durable Medical Equipment Medicare Administrative Contractor (DME MAC A55426) for Jurisdiction C, Updated Date: 06/12/2018. Accessed on the Internet 08/20/2018.

3. CMS, Standard Documentation Requirement for All Claims Submitted to DME MACs (A55426), revised effective date: 05/07/2018. Accessed 08/20/2018.

4. CMS; Automatic External Defibrillators (L33690); revision effective date: 01/01/2017, Accessed 08/20/2018.

5. Centers for Medicare and Medicaid Services. Durable Medical Equipment Reference List, National Coverage Determination 280.1 Effective Date: 5-5-05, Version Number 2. Accessed 08/21/2018

6. National Guideline Clearinghouse. Evidence-based clinical practice guidelines: primary monosymptomatic nocturnal enuresis in primary care. October 2005. Accessed on the Internet at http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=12239&string=enuresis.

7. Hayes Directory, © Winifred S. Hayes, Inc. Light Therapy for Seasonal Affective Disorder. March 20, 2005. Archived Oct 07, 2015. [Cited 03/18/2019].

8. New Mexico Human Services Department, Medical Assistance Division Program Policy Manual. General Non-covered Services, NMAC 8.301.3.15., Accessed 08/24/2018

9. MCG Health Ambulatory Care, 21th Edition. Graduated Compression Stockings: ACG: A-0336 (AC) Last update: 02-02-17. Accessed 08/21/2018.

10. MCG Health Ambulatory Care 21st Edition, Ambulatory Blood Pressure Monitoring, 24-Hour. ACG: A-0123(AC). Last update: 02-02/2017, Accessed 09/11/2018.

11. New Mexico Legislature. Senate Bill 529. New Mexico Act: Requiring Insurance Coverage for Hearing Aids for Eligible Children. Effective Date of Provisions :07-01-07.

12. CMS, Medicare Benefit Policy Manual, Chapter 15, 110 Durable Medical Equipment – General. Rev. 241, on 02/02/2018. Accessed 09/12/2018.

13. Affordable Care Act, Healthcare .Gov. Breast Feeding Benefits. CMS.The Center for Consumer Information & Insurance Oversight.

Medical Policy Original Effective Date: 05-22-06

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

Accessed 08/21/2018. 14. CMS NCD (230.4) for Diagnosis and Treatment of Impotence,

Version 1, Effective Date: Longstanding and not been posted. Accessed: 08/22/2018.

15. CMS, MLN Matters® Number: SE1511, Discontinued Coverage of Vacuum Erection Systems (VES) Prosthetic Devices in Accordance with the Achieving a Better Life Experience Act of 2014 Effective Date: July 1, 2015, Accessed 08/22/2018

16. CMS NCD for Home Prothrombin Time/International Normalized Ratio (PT/INR) Monitoring for Anticoagulation Management (190.11), Version 2, Implementation Date: 08/25/2008. Accessed Date: 08/22/2018.

17. CMS Manual System, Pub 100.-04 Medicare Claims Processing, Transmittal 1562

18. CMS Manual System, Pub 100-20, Transmittal 2138 (for HCPCS codes), Date: July 25, 2008. [Cited 03/18/2019]

19. CMS, ICD-10 for Home PT/INR per CMS Manual, Pub 100-20, Transmittal 2122, Transmittal 2122, Date: August 10, 2018. Accessed August 27, 2018.

20. CMS National Coverage Determination for Non-Implantable Pelvic Floor Electrical Stimulator (230.8), Version 2, Implementation Date: 06/19/2006. Accessed 08/22/2018.

21. MCG, 21st Edition, Pelvic Floor Rehabilitation, A-0371, Last Update: 02/02/2017. Accessed 08/22/2018

22. Aetna, Phototherapy for Psychiatric Disorders, Number 0370, Last Review 08/14/2018, Next Review 04/11/2019. Accessed 09/11/2018

23. Aetna, Breast Pumps, Number 0421, last review 08/22/2018, next review 04/25/2019. Accessed 11/12/2018.

Reviewed by: Mike Nelson, MD, Presbyterian Medical Group Pediatrics, September 2006 (for Enuresis Alarms).

Approval Signatures: Clinical Quality Committee: Norman White MD Medical Director: David Yu MD

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

Approval Date March 27, 2019

Publication History:

April 1999: Original effective date of Health Services DME Criteria 05-28-08: Merging of Health Services DME Criteria, Benefit Alerts

and benefit interpretation; transitioned central DME Criteria to four separate Medical Policies.

06-24-09: Annual Review and Revision 01-27-10: Revision to Hearing Aid coverage 06-23-10: Annual Review and Revision 08-24-11: Annual Review 02-22-12: Corrected language re: Comfort and convenience items. 12-10-12 Removed HCPCS code A6549 from policy and table. Not

covered. 01-27-16 Annual Review. Added language re: Hospital Grade breast

pumps. Added Attachment A. List of items that do not meet definition of DME by CMS.

03-27-19 Annual Review with added information on enteral nutritional supplements and products.

This Medical Policy is intended to represent clinical guidelines describing medical appropriateness and is developed to assist Presbyterian Health Plan and Presbyterian Insurance Company, Inc. (Presbyterian) Health Services staff and Presbyterian medical directors in determination of coverage. This Medical Policy is not a treatment guide and should not be used as such.

For those instances where a member does not meet the criteria described in these guidelines, additional information supporting medical necessity is welcome and may be utilized by the medical director in reviewing the case. Please note that all Presbyterian Medical Policies are available on the Internet at http://www.phs.org/phs/healthplans/providers/healthservices/Medical/index.htm

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

Attachment A Non-Covered Durable Medical Equipment Reference List

For NMAC Non-Covered Durable Medical Equipment and Medical Supplies see NM Administrative Code number 8.301.3. Those non-covered services that are not listed in this area. Please visit the site for more details on those non-covered services. CMS NCD (280.1) Item/Service Description: National Coverage Determination (ND) for Durable Medical Equipment Reference List (280.1). Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service. The first column lists alphabetically various generic categories of equipment on which national coverage decisions have been made by CMS; and the second column notes the coverage status of each equipment category.

Items Non- Covered Durable Medical Equipment Reference List Air Cleaners Deny - environmental control equipment; not primarily medical

in nature (§1861(n) of the Act). Air Conditioners Deny - environmental control equipment; not primarily medical

in nature (§1861 (n) of the Act). Air-Fluidized Beds (See Air-Fluidized Beds, §280.8 of the NCD Manual.) Alternating PRESSURE Pads, Mattresses and Lamb's Wool Pads

Covered if patient has, or is highly susceptible to, decubitus ulcers and the patient’s physician specifies that he/she has specified that he will be supervising the course of treatment.

Audible/Visible Signal/Pacemaker MONITORs

(See Self-Contained Pacemaker MONITORs.)

Augmentative Communication Devices

(See Speech Generating Devices §50.1 of this manual.)

Bathtub Lifts Deny - convenience item; not primarily medical in nature (§1861(n) of the Act).

Bathtub Seats Deny - comfort or convenience item; hygienic equipment; not primarily medical in nature (§1861(n) of the Act).

Bead Beds (See §280.8.) Bed Baths (home type) Deny - hygienic equipment; not primarily medical in nature

(§1861(n) of the Act). Bed Lifters (bed elevators ) Deny - not primarily medical in nature (§1861(n) of the Act). Bedboards Deny - not primarily medical in nature (§1861(n) of the Act). Bed Pans (autoclavable hospital type)

Covered if patient is bed confined.

Bed Side Rails (See Hospital Beds, §280.7 of this manual.) Beds-Lounges (power or manual)

Deny - not a hospital bed; comfort or convenience item; not primarily medical in nature (§1861(n) of the Act).

Beds (Oscillating) Deny - institutional equipment; inappropriate for home use. Bidet Toilet Seats (See Toilet Seats.) BLOOD Glucose Analyzers (Reflectance Colorimeter)

Deny - unsuitable for home use (see §40.2 of this manual).

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

Items Non- Covered Durable Medical Equipment Reference List BLOOD Glucose MONITORs

Covered if patient meets certain conditions (see §40.2 of this manual).

Braille Teaching Texts Deny - educational equipment; not primarily medical in nature (§1861(n) of the Act).

Canes Covered if patient meets Mobility Assistive Equipment clinical criteria (see §280.3 of this manual).

Carafes Deny - convenience item; not primarily medical in nature (§1861(n) of the Act).

Catheters Deny - nonreusable disposable supply (§1861(n) of the Act). (See The Medicare Claims Processing Manual, Chapter 20, DMEPOS).

Commodes Covered if patient is confined to bed or room NOTE: The term “room confined” means that the patient’s condition is such that leaving the room is medically contraindicated. The accessibility of bathroom facilities generally would not be a factor in this determination. However, confinement of a patient to a home in a case where there are no toilet facilities in the home may be equated to room confinement. Moreover, payment may also be made if a patient’s medical condition confines him to a floor of the home and there is no bathroom located on that floor.

Communicators (See §50.1 of this manual, Speech Generating Devices.) Continuous Passive Motion Devices

Continuous passive motion devices are devices Covered for patients who have received a total knee replacement. To qualify for coverage, use of the device must commence within 2 days following surgery. In addition, coverage is limited to that portion of the 3-week period following surgery during which the device is used in the patient’s home. There is insufficient evidence to justify coverage of these devices for longer periods of time or for other applications.

Continuous Positive Airway PRESSURE (CPAP) Devices

(See §240.4 of this manual.) or see also MPM 4.3

Crutches Covered if patient meets Mobility Assistive Equipment clinical criteria (see section 280.3 of this manual), or see also MPM 4.2

Cushion Lift Power Seats (See Seat Lifts.) Dehumidifiers (room or central heating system type)

Deny - environmental control equipment; not primarily medical in nature (§1861(n) of the Act).

Diathermy Machines (standard pulses wave types)

Deny - inappropriate for home use (see §150.5 of this manual).

Digital Electronic Pacemaker MONITORs

(See Self-Contained Pacemaker MONITORs .)

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

Items Non- Covered Durable Medical Equipment Reference List Disposable Sheets and Bags

Deny - non-reusable disposable supplies (§1861(n) of the Act).

Elastic Stockings Deny - non-reusable supply; not rental-type items (§1861(n) of the Act). (See §270.5 of this manual.)

Electric Air Cleaners Deny - (See Air Cleaners.) (§1861(n) of the Act). Electric Hospital Beds (See Hospital Beds §280.7 of this manual.) Electrical Stimulation for Wounds

Deny - inappropriate for home use. (See §270.1 of this manual.)

Electrostatic Machines Deny - (See Air Cleaners and Air Conditioners.) (§1861(n) of the Act).

Elevators Deny - convenience item; not primarily medical in nature (§1861(n) of the Act).

Emesis Basins Deny - convenience item; not primarily medical in nature (§1861(n) of the Act).

Esophageal Dilators Deny - physician instrument; inappropriate for patient use. Exercise Equipment Deny - not primarily medical in nature (§1861(n) of the Act). Fabric Supports Deny - nonreusable supplies; not rental-type items (§1861(n) of

the Act). Face Masks (oxygen) Covered if oxygen is covered. (See §240.2 of this manual.) Face Masks (surgical) Deny - nonreusable disposable items (§1861(n) of the Act). Flow Meters (See Medical Oxygen Regulators.) (See §240.2 of this manual.) Fluidic Breathing Assisters (See Intermittent Positive PRESSURE Breathing Machines.) Fomentation Devices (See Heating Pads.) Gel Flotation Pads and Mattresses

(See Alternating PRESSURE Pads and Mattresses.)

Grab Bars Deny - self-help device; not primarily medical in nature (§1861(n) of the Act).

Heat and Massage Foam Cushion Pads

Deny - not primarily medical in nature; personal comfort item (§1861(n) and 1862(a)(6) of the Act).

Heating and Cooling Plants

Deny - environmental control equipment not primarily medical in nature (§1861(n) of the Act).

Heating Pads Covered if MAC's medical staff determines patient’s medical condition is one for which the application of heat in the form of a heating pad is therapeutically effective.

Heat Lamps Covered if MAC's medical staff determines patient’s medical condition is one for which the application of heat in the form of a heat lamp is therapeutically effective.

Hospital Beds (See §280.7 of this manual.) Hot Packs (See Heating Pads.) Humidifiers (oxygen) (See Oxygen Humidifiers.) Humidifiers (room or central heating system

Deny - environmental control equipment; not medical in nature (§1861(n) of the Act).

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

Items Non- Covered Durable Medical Equipment Reference List types) Hydraulic Lifts (See Patient Lifts.) Incontinent Pads Deny - nonreusable supply; hygienic item (§1861(n) of the Act). Infusion Pumps For external and implantable pumps, see §40.2 of this manual.

If pump is used with an enteral or parenteral nutritional therapy system, see §180.2 of this manual for special coverage rules.

Injectors (hypodermic jet) Deny - not covered self-administered drug supply;PRESSURE powered devices (§1861(s)(2)(A) of the Act) for injection of insulin.

Intermittent Positive PRESSURE Breathing Machines

Covered if patient’s ability to breathe is severely impaired.

Iron Lungs (See Ventilators.) Irrigating Kits Deny - nonreusable supply; hygienic equipment (§1861(n) of the

Act). Lamb's Wool Pads (See Alternating PRESSURE Pads, Mattresses, and Lamb's

Wool Pads.) Leotards Deny - (See PRESSURE Leotards.) (§1861(n) of the Act). Lymphedema Pumps Covered (See Pneumatic Compression Devices, §280.6 of this

manual.) Massage Devices Deny - personal comfort items; not primarily medical in nature

(§1861(n) and 1862(a)(6) of the Act). Mattresses Covered only where hospital bed is medically necessary.

(Separate Charge for replacement mattress should not be allowed where hospital bed with mattress is rented.) (See §280.7 of this manual.)

Medical Oxygen Regulators

Covered if patient’s ability to breathe is severely impaired. (See §240.2 of this manual.)

Mobile Geriatric Chairs Covered if patient meets Mobility Assistive Equipment clinical criteria (see §280.3 of this manual). (See Rolling Chairs).

Motorized Wheelchairs Covered if patient meets Mobility Assistive Equipment clinical criteria (see §280.3 of this manual).

Muscle Stimulators Covered for certain conditions. (See §250.4 of this manual.) Nebulizers Covered if patient’s ability to breathe is severely impaired. Oscillating Beds Deny - institutional equipment - inappropriate for home use. Over-bed Tables Deny - convenience item; not primarily medical in nature

(§1861(n) of the Act). Oxygen Covered if the oxygen has been prescribed for use in

connection with medically necessary DME . (See §240.2 of this manual.)

Oxygen Humidifiers Covered if the oxygen has been prescribed for use in connection with medically necessary DME for purposes of moisturizing oxygen. (See §240.2 of this manual.)

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Durable Medical Equipment (DME): Miscellaneous MPM 4.5

Items Non- Covered Durable Medical Equipment Reference List Oxygen Regulators (Medical)

(See Medical Oxygen Regulators.)

Oxygen Tents (See §240.2 of this manual.) Paraffin Bath Units (Portable)

(See Portable Paraffin Bath Units.)

Paraffin Bath Units (Standard)

Deny - institutional equipment; inappropriate for home use.

Parallel Bars Deny - support exercise equipment; primarily for institutional use; in the home setting other devices (e.g., walkers ) satisfy patient’s need.

Patient Lifts Covered if MAC's medical staff determines patient’s condition is such that periodic movement is necessary to effect improvement or to arrest/retard deterioration condition.

Percussors> Covered for mobilizing respiratory tract secretions in patients with chronic obstructive lung disease, chronic bronchitis, or emphysema, when patient or operator of powered percussor receives appropriate training by a physician or therapist, and no one competent to administer manual therapy is available.

Portable Oxygen SYSTEMS

1. Regulated Covered (adjustable Covered under conditions specified in a flow rate). Refer all claims to medical staff for this determination.

2. Preset Deny - (flow rate Deny - emergency, first-aid, or not adjustable) precautionary equipment; essentially not therapeutic in nature

Portable Paraffin Bath Units

Covered when the patient has undergone a successful trial period of paraffin therapy ordered by a physician and the patient’s condition is expected to be relieved by long term use of this modality.

Portable Room Heaters Deny - environmental control equipment; not primarily medical in nature (§1861(n) of the Act).

Portable Whirlpool Pumps Deny - not primarily medical in nature; personal comfort items (§§1861(n) and 1862(a)(6) of the Act).

Postural Drainage Boards Covered if patient has a chronic pulmonary condition. Preset Portable Oxygen Units

Deny - emergency, first-aid, or precautionary equipment; essentially not therapeutic in nature.

PRESSURE Leotards Deny - non-reusable supply, not rental-type item (§1861(n) of the Act).

Pulse Tachometers Deny - not reasonable or necessary for MONITORing pulse of homebound patient with/without a cardiac pacemaker.

Quad-Canes Covered if patient meets Mobility Assistive Equipment clinical criteria (see §280.3 of this manual).

Raised Toilet Seats Deny - convenience item; hygienic equipment; not primarily medical in nature (§1861(n) of the Act).

Medical Policy Original Effective Date: 05-22-06

Revised Date: 03-27-2019 Page 33 of 34

Durable Medical Equipment (DME): Miscellaneous MPM 4.5

Items Non- Covered Durable Medical Equipment Reference List Reflectance Colorimeters (See BLOOD Glucose Analyzers.) Respirators (See Ventilators.) Rolling Chairs Covered if patient meets Mobility Assistive Equipment clinical

criteria (see §280.3 of the NCD Manual). Coverage is limited to those roll-about chairs having casters of at least 5 inches in diameter and specifically designed to meet the needs of ill, injured, or otherwise impaired individuals. Coverage is denied for the wide range of chairs with smaller casters as are found in general use in homes, offices, and institutions for many purposes not related to the care/treatment of ill/injured persons. This type is not primarily medical in nature. (§1861(n) of the Act.)

Safety Rollers Covered if patient meets Mobility Assistive Equipment clinical criteria (see §280.3 of this manual).

Sauna Baths Deny - not primarily medical in nature; personal comfort items (§§1861(n) and 1862(a)(6) of the Act).

Seat Lifts Covered under the conditions specified in §280.4 of this manual. Refer all to medical staff for this determination.

Self Contained Pacemaker MONITORs

Covered when prescribed by a physician for a patient with a cardiac pacemaker. (See §§20.8.1 and 280.2 of this manual.)

Sitz Baths Covered if MAC's medical staff determines patient has an infection or injury of the perineal area and the item has been prescribed by the patient’s physician as a part of his planned regimen of treatment in the patient’s home.

Spare Tanks of Oxygen Deny - convenience or precautionary supply. Speech Teaching Machines

Deny - education equipment; not primarily medical in nature (§1861(n) of the Act).

Stairway Elevators Deny - (See Elevators.) (§1861(n) of the Act). Standing Tables Deny - convenience item; not primarily medical in nature

(§1861(n) of the Act). Steam Packs These packs are Covered under the same conditions as heating

pads. (See Heating Pads.) Suction Machines Covered if MAC's medical staff determines that the machine

specified in the claim is medically required and appropriate for home use without technical or professional supervision.

Support Hose Deny - (See Fabric Supports.) (§1861(n) of the Act). Surgical Leggings Deny - non-reusable supply; not rental-type item (§1861(n) of

the Act). Telephone Alert SYSTEMS

Deny - these are emergency communications SYSTEMS and do not serve a diagnostic or therapeutic purpose.

Toilet Seats Deny - not medical equipment (§1861(n) of the Act). Traction Equipment Covered if patient has orthopedic impairment requiring traction

equipment that prevents ambulation during the period of use

Medical Policy Original Effective Date: 05-22-06

Revised Date: 03-27-2019 Page 34 of 34

Durable Medical Equipment (DME): Miscellaneous MPM 4.5

Items Non- Covered Durable Medical Equipment Reference List (Consider covering devices usable during ambulation; e.g., cervical traction collar, under the brace provision).

Trapeze Bars Covered if patient is bed confined and the patient needs a trapeze bar to sit up because of respiratory condition, to change body position for other medical reasons, or to get in and out of bed.

Treadmill Exercisers Deny - exercise equipment; not primarily medical in nature (§1861(n) of the Act).

Ultraviolet Cabinets Covered for selected patients with generalized intractable psoriasis. Using appropriate consultation, the MAC should determine whether medical and other factors justify treatment at home rather than at alternative sites, e.g., outpatient department of a hospital.

Urinals autoclavable Covered if patient is bed confined (hospital type). Vaporizers Covered if patient has a respiratory illness. Ventilators Covered for treatment of neuromuscular diseases, thoracic

restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary disease. Includes both positive and negative PRESSURE types. (See §240.5 of this manual.)

Walkers Covered if patient meets Mobility Assistive Equipment clinical criteria (see §280.3 of this manual).

Water and PRESSURE Pads and Mattresses

(See Alternating PRESSURE Pads, Mattresses and Lamb's Wool Pads.)

Wheelchairs (manual) Covered if patient meets Mobility Assistive Equipment clinical criteria (see §280.3 of this manual).

Wheelchairs (power operated)

Covered if patient meets Mobility Assistive Equipment clinical criteria (see §280.3 of this manual).

Wheelchairs (scooter/POV)

Covered if patient meets Mobility Assistive Equipment clinical criteria (see §280.3 of this manual).

Wheelchairs (specially-sized)

Covered if patient meets Mobility Assistive Equipment clinical criteria (see §280.3 of this manual).

Whirlpool Bath Equipment Covered if patient is homebound and has a (standard)condition for which the whirlpool bath can be expected to provide substantial therapeutic benefit justifying its cost. Where patient is not homebound but has such a condition, payment is restricted to the cost of providing the services elsewhere; e.g., an outpatient department of a participating hospital, if that alternative is less costly. In all cases, refer claim to medical staff for a determination.

Whirlpool Pumps Deny - (See Portable Whirlpool Pumps.) (§1861(n) of the Act). White Canes Deny - (See §280.2 of this manual.) (Not considered Mobility

Assistive Equipment)