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.