3.0 Coverage Criteria
3.1 Covered items
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
is provided
on a rental or purchase basis.
3.2.1 Coverage
of DE is based upon 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 includes 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 United
States (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
is 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
upon 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)
is covered, except as authorized
in
paragraphs 3.6,
3.8, or
4.1.
3.4 The item of DE is 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
is not
otherwise
excluded by the regulation and policy (
i.e.,
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
).
3.6 DME
is DE (
see paragraph 2.2)
that
is medically appropriate as defined in 32
CFR 199.2
(see the TOM, Appendix A).
DME
Customization. Customization of DME (
i.e., 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
) are
covered when medically necessary.
• Accessories for hospital beds are also 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 are not 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 are allowed
to cover only the installation of the allowable vehicle wheelchair lift.
3.8.2.2 The TRICARE Program 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 has “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 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 The TRICARE Program’s allowable
charge is based upon 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 are
not 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 are covered when 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 is 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 shall 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 The TRICARE Program 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 upon 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 as an
item of DE previously cost-shared by the TRICARE Program.
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. Another example is an
electric wheelchair, which otherwise meets the definition of DE
would not be duplicative of a manual wheelchair previously cost-shared
by the TRICARE Program 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 3.10),
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
upon 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
(i.e., withstand
s repeated
use
). Therefore, DE does not include expendable
items
(e.g., incontinent pads, diapers,
ace bandages
). 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
). 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) are excluded.