2.0 POLICY
2.1 DE,
which is a medically necessary and appropriate item, ordered by
a TRICARE authorized individual professional provider for the specific
use of the beneficiary, and which complies with the following DE
definition and coverage criteria may be cost-shared. A TRICARE authorized
individual professional provider who may order or prescribe DE is
a physician, a dentist, or any TRICARE authorized allied health
care professional as described in
32 CFR 199.6(c)(3)(ii) and
(c)(3)(iii), when acting within the scope
of their license or certification, including the following:
• Doctors of Podiatric
Medicine (DPMs).
• Doctors of Optometry
(ODs).
• Certified Physician
Assistants (CPAs).
• Certified
Clinical Nurse Specialists (CCNSs) when recognized by TRICARE as:
• Certified Nurse
Practitioners (CNPs),
• Certified
Nurse Midwives (CNMs), or
• Certified
Psychiatric Nurse Specialists (CPNSs).
• Certified
Registered Nurse Anesthetists (CRNAs).
• Certified
Psychiatric Nurse Specialists (CPNSs).
• Licensed
Physical Therapists.
• Licensed
and Registered Occupational Therapists.
2.2 Definition. As defined in the
32 CFR 199.2, DE is a medically necessary
item that:
2.2.1 Can withstand repeated use;
2.2.2 Is primarily
and customarily to serve a medical purpose; and
2.2.3 Is generally not useful to an individual in
the absence of an illness or injury.
3.0 Coverage
Criteria
3.1 Covered items that may be provided to a beneficiary
as DE includes the following:
• Hospital
beds.
• Iron lungs.
• Durable
Medical Equipment (DME).
• Wheelchairs.
• Cardiorespiratory
monitor under conditions specified in
Section 2.2.
3.2 A covered DE shall be provided on a rental
or purchase basis.
3.2.1 Coverage of DE shall be based
on the price most advantageous to the government, taking into consideration
the anticipated duration of the medically necessary need for the
equipment and current price information for the type of item.
3.2.2 The cost analysis must include a comparison
of the total price of the item as a monthly rental charge, a lease-purchase
price, and a lump-sum purchase price and a provision for the time
value of money at the rate determined by the U.S. Department of
Treasury.
3.3 A prescribed item of DE that provides the medically
appropriate level of performance and quality for the beneficiary’s
medical condition present must be supported by adequate documentation,
as defined in
32 CFR 199.2.
Luxury, deluxe, immaterial, or non-essential features, which increase
the cost of the item relative to a similar item without those features,
based on industry standards for a particular item at the time the
equipment is prescribed or replaced for a beneficiary, are not authorized.
Only the “base” or “basic” model of equipment (or more cost-effective
alternative equipment) shall be covered, except as authorized in
paragraphs 3.6,
3.8,
or
4.1.
3.4 The item of DE must be prescribed for a use
consistent with required U.S. Food and Drug Administration (FDA)
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 requirement of FDA approval is met.
3.5 The item of DE must not be otherwise excluded
by the regulation and policy (for example, those found in
32 CFR 199.4(g), to include communication
devices other than those allowed in
Chapter 7, Section 23.1, eyeglasses, exercise/relaxation/comfort
devices, comfort or convenience items, etc.).
3.6 Durable Medical Equipment (DME) is DE (as defined
in
paragraph 2.2) that meets the following additional
coverage criteria:
3.6.1 It is medically appropriate
to:
3.6.1.1 Improve, restore, or maintain the function
of a malformed, diseased, or injured body part, or can otherwise
minimize or prevent the deterioration of the beneficiary’s function
or condition; or
3.6.1.2 Maximize
the beneficiary’s function consistent with the beneficiary’s physiological
or medical needs.
3.6.2 DME
Customization. Customization of DME (equipment designed permanently
to preclude the use of such equipment by another individual) owned
by a beneficiary, and any accessory or item of supply for any such
equipment, may be covered as determined by the Director (or designee)
to be essential for:
• Achieving
therapeutic benefit for the patient;
• Making
the equipment serviceable; or
• Otherwise
assuring the proper functioning of the equipment.
3.7 Hospital beds (e.g., a manual or electric fixed
height, variable height, semi-electric, heavy duty extra wide, extra
heavy duty, etc.) are covered when medically necessary.
• Accessories for hospital
beds may also be covered when medically necessary.
3.8 Wheelchairs, which otherwise meet the DE definition
in
paragraph 2.2, are covered to provide medically
appropriate basic mobility.
3.8.1 Electric wheelchairs. An electric
wheelchair, or TRICARE approved alternative to an electric wheelchair
(e.g., scooter), may be provided in lieu of a manual wheelchair
to provide basic mobility. Benefits will not be extended for the
use of both an electric-powered, cart-type vehicle and an electric wheelchair
during the same period of time.
3.8.2 Lifts. A vehicle lift, which otherwise meets
the requirements of
paragraph 3.3 and all other applicable provisions
of this policy, may be covered when necessary to transport an otherwise authorized
wheelchair (or an approved alternative). Coverage is limited to
the basic model lift and must be a temporary (non-permanent/transferable)
lift that transports the wheelchair itself (or an approved alternative).
3.8.2.1 Labor charges may be allowed to cover only
the installation of the allowable vehicle wheelchair lift.
3.8.2.2 TRICARE does not cover transportation of beneficiaries,
including to and from medical appointments, except for ambulances
when medical care is provided to the individual in transit. A lift may
be authorized solely to transport the wheelchair so that a traveling
beneficiary may have “basic” mobility once at his or her destination.
3.8.2.3 Vehicle conversions are excluded. That is conversions
such as but not limited to, raising the roof, widening the door,
or permanent attachments installed (e.g., items that are non-transferable
to another vehicle). Purchases and (or) conversions of personal
vehicles for a wheelchair bound beneficiary fall outside the scope
of the TRICARE medical benefits and, therefore, are excluded.
3.8.2.4 TRICARE’s allowable charge is based on the
basic (or standard) model lift and authorized installation fees.
Lifts beyond the basic (or standard) model required for transport
of an authorized wheelchair are excluded from TRICARE coverage and
cannot be considered in determining the TRICARE allowable costs.
Beneficiaries who choose a lift other than the basic (or standard)
model (i.e., luxury/deluxe) are responsible for the costs above
and beyond the allowable amount of the basic lift. In such a case,
the beneficiary is responsible for submitting sufficient information
regarding the otherwise authorized basic model lift and costs of
installation along with the itemized costs of the luxury/deluxe model
and installation costs.
Note: Refer to
paragraph 4.0 for TRICARE description of “any
item of DE beyond the basic/standard model.”
3.8.3 Modifications of wheelchairs. Medically appropriate
modifications (i.e., slight or small changes or alterations) to
the wheelchair (or an approved alternative) to accommodate a particular physiological
or medical need may be covered if necessary to provide basic mobility
and to allow proper use of the wheelchair. When an otherwise covered
wheelchair requires substantial modification, or is uniquely built
to meet the special needs of a beneficiary, for basic mobility and
proper use of the wheelchair, coverage may be provided only under
a lump-sum purchase or rental-purchase agreement resulting in the
beneficiary owning the modified wheelchair.
3.9 Repairs. Benefits are allowed for repair of
beneficiary-owned DE when necessary to make the equipment functional
because of reasonable wear and usage and the manufacturer’s warranty
has expired, but only on the condition that the repair cost is less
than the replacement cost. Coverage includes the use of a temporary
replacement item provided during a reasonable period of repair.
3.10 Replacements. Benefits are allowed for replacement
of beneficiary-owned DE with documentation that the DE is lost or
stolen and not otherwise covered by another insurance (such as a homeowner’s
policy). Replacement of beneficiary-owned DE is also allowed when
the item is not functional due to normal wear, accidental damage,
a change in the beneficiary’s condition, or the device has been
declared adulterated by the FDA. (Exceptions exist for prosthetic
devices; see
Section 4.1 for more information.)
Note: Replacement is
subject to review of documentation supporting why the current DE
item is no longer usable/repairable and that the replacement cost
is less than the repair cost.
Note: Replacement equipment is allowed only upon a new
order or prescription by a TRICARE authorized individual professional
provider with an explanation of the medical need.
3.10.1 When a rented item of DE is lost or stolen,
the supplier is required to use modifier RA to notify
the TRICARE contractor that the item has been lost or stolen, and
a replacement item is being provided. Payment for the original rented
item of DE that was lost or stolen is the contractual responsibility
of the supplier.
3.10.2 TRICARE
will not continue to pay rental fees on equipment that has been
lost or stolen. Once the medically necessary DE has been replaced
by the supplier and provided to the beneficiary, rental fees for
the replacement item shall resume based on the continuous use provision,
if applicable.
3.11 An item of DE which otherwise meets the DE
benefits requirement that is essential to provide a fail-safe in-home
life-support system, or that replace in-like-kind an item of equipment
that is not serviceable because of normal wear, accidental damage,
a change in the beneficiary’s condition, has been declared adulterated
by the FDA, or is being, or has been recalled by the manufacturer,
is not considered duplicate and, therefore is covered.
Note: For the purpose
of this policy, “duplicate” means an item of equipment that meets
the definition of DE and serves the same purpose that is served
by an item of DE previously cost-shared by TRICARE. For example,
various models of a stationary oxygen concentrator with no significant differences
are considered duplicates, whereas stationary and portable concentrators
are not considered duplicates of each other because the latter is
intended to provide a beneficiary with mobility outside the home.
Also for example, an electric wheelchair, which otherwise meets
the definition of DE would not be duplicative of a manual wheelchair
previously cost-shared by TRICARE in that the electric wheelchair
provides independent mobility not provided by the manual wheelchair.
5.0 EXCLUSIONS
5.1 DE for a beneficiary who is a patient in a
type of facility that ordinarily provides the same type of DME item
to its patients at no additional charge in the usual course of providing
its services is excluded.
5.2 DE that is available to the beneficiary from
a Uniformed Services Medical Treatment Facility (USMTF).
5.3 An item of DE that has been lost or stolen
(except as provided in paragraph 3.9), or for an item under warranty,
or when a DE is damaged while using the equipment in a manner inconsistent
with its common use.
5.4 DE with luxury, deluxe, immaterial,
or non-essential features, which increase the cost of the item relative
to a similar item without those features, based on industry standards
for a particular item at the time the equipment is prescribed or
replaced for a beneficiary. (See
paragraph 4.0 for Policy Consideration.)
5.5 Exercise, relaxation, comfort, sporting items,
or sporting devices. Exercise equipment, to include wheelchairs
and items primarily and customarily designed for use in sports or
recreational activities, spas, whirlpools, hot tubs, swimming pools
health club memberships or other such charges, or items.
5.6 Repairs of deluxe, luxury, or immaterial features
of DE (except as provided in
paragraph 3.9),
5.7 Repairs of DE damaged while using the equipment
in a manner inconsistent with its common use.
5.8 Maintenance agreement.
5.9 Routine periodic servicing, such as testing,
cleaning, regulating, and checking which the manufacturer does not
require be performed by an authorized technician.
5.10 Duplicate items of otherwise allowable DE to
be used solely as a back-up to currently owned or rented equipment,
except as provided in
paragraph 3.11.
5.11 DE must be considered durable -- can withstand
repeated use. Therefore, DE does not include expendable items such
as incontinent pads, diapers, ace bandages, etc. Such items are
excluded from DE coverage. Refer to
Section 6.1 for
policy regarding supplies and dressings (consumables).
5.12 Non-medical equipment (e.g., humidifier, electric
air cleaners, exercycle, safety grab bars, training equipment, etc.).
See
32 CFR 199.4.
5.13 Beds that are not medical in nature and used
for comfort or convenience (e.g, power or manual lounge beds, sleep-number
beds, ordinary beds typically sold as furniture, etc.) are excluded.