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.