HI 00610.300 Examples of Durable Medical Equipment Covered and Not Covered

Intermediaries and carriers have been instructed to process purchases and rental of durable medical equipment to agree with column II. In certain claims, the contractor's (intermediary or carrier) physician staff must evaluate the medical need(s) of the beneficiary before a coverage determination can be made. (See HI 00610.190.) If the beneficiary is outside the United States when purchased durable medical equipment is delivered, see HI 00610.240.

Column I Item Column II Coverage Status
Action Bath Hydro Massage deny—(see Portable Whirlpool Pumps)
Adjust-A-Bed deny—(see Beds-Lounge)
Aero Massage deny—(See Portable Whirlpool Pumps)
Aero-Pulse Surgical Leggings deny—(see Surgical Leggings)
Air Cleaners deny—environmental control equipment: not primarily medical in nature
Air-Fluidized Bed (see Bead Bed)
Alternating Pressure Pads and Mattresses covered if contractor's physician determines patient has, or is highly susceptible to, decubitus ulcers and patient's physician has prescribed the equipment for treatment and has specified in the prescription that he will be supervising its use in connection with his course of treatment
American Bidet Toilet Seat deny—hygienic equipment
American Sonoid Heat and Massage Foam Cushion Pad deny—not generally accepted by the medical profession as being therapeutically effective.
Aqua-Whirl (see Portable Whirlpool Pumps)
Aquamatic K-Pad covered under same conditions as heating pad. Limit payment to amount which would be payable for ordinary heating pad
Aquamatic K-Thermai deny—institutional type equipment; inappropriate for home use
Aquasage Portable Whirlpool Pumps deny—(see Portable Whirlpool Pumps)
Arteroisonde see Automatic Blood Pressure Monitor
Artificial Kidney coverage for chronic renal failure under certain conditions. Refer all claims to medical staff for this determination.
Astromatic Bed deny—(see Beds-Lounge)
Astropedic Bed deny—(see Beds-Lounge)
Astro Comfort A. Bed deny—(see Beds—Lounge
Audible/Visible Signal Pacemaker Monitor (see Self-Contained Pacemaker Monitor)
Autolift deny—(see Bathtub Lifts)
Automatic Blood Pressure covered if prescribed by a physician for use as part of home dialysis delivery system. However, reimbursement is limited to the amount which would be payable for a sphygmomanometer with cuff and stethoscope unless there is documentation that the patient's condition is such that conventional methods of monitoring are not successful. Where the patient has such a condition, payment will be limited to the amount which would be payable for the least expensive automatic blood pressure monitor which is medically effective. Where documentation is not in file and does not accompany the physician's prescription, the intermediary should contact the physician to determine whether such a condition exists.
Autosfig deny—physician instrument
Auto-Tilt Chair deny—not generally accepted by the medical profession as being therapeutically effective.
Bathtub Lifts deny—convenience item; not primarily medical in nature.
Bathtub Seats deny—comfort or convenience item; hygienic equipment; not primarily medical in nature.
Bead Bed deny—institutional equipment; inappropriate for home use.
Beautyrest Adjustable Bed deny—(see Beds-Lounge)
Bed Baths (home type) deny—hygienic equipment.
Bed Lifter deny—not primarily medical in nature.
Bedboards deny—not primarily medical in nature.
Bed Pans (autoclavable hospital type) covered if patient is bed confined (see Hospital Beds for definition of “bed confined”).
Bed Side Rails covered if patient is bed confined and has one of the following conditions: He is disoriented; experiences vertigo; or has a neurological disorder resulting in incidence of convulsive seizures (see Hospital Beds for definition of “bed confined”)
Beds-Lounge (power or manual) deny—not a hospital bed; comfort or convenience item; not primarily medical in nature.
Beds—Oscillating deny—institutional equipment; inappropriate for home use.
Bell and Howell Language Master deny—(see Speech Teaching Machines)
Bendix Respiratory Support System covered if patient's ability to breathe is severely impaired.
Bidet Toilet Seat deny—(see American Bidet Toilet Seat)
Bennett IPPB Machine covered if patient's ability to breathe is severely impaired.
Bird Respirator (IPPB machine) covered if patient's ability to breathe is severely impaired.
Blood Glucose Analyzer-Reflectance Colorimeter deny—unsuitable for home use.
Braille Teaching Texts deny—education equipment; not primarily medical in nature.
Burke Bed Elevator deny—(see Bed Lifter)
Burke Electric Portable Commode Erector deny—(see Raised Toilet Seats)
Burke Elevator Chair (see Seat Lift)
Burke Toilet Seat Erector deny—(see Raised Toilet Seats)
Canes covered if patient's condition impairs ambulation
Carafes deny—convenience item; not primarily medical in nature
Catheters deny—nonreusable disposable supply
Centrifuge Readacrit covered when prescribed by a physician for use by a patient on home hemodialysis
Century Bed Bath deny—(see Bed Baths)
Cheney Safety Bath Lift deny—convenience item; not primarily medical in nature
Circulator deny—institutional or physician equipment; inappropriate for home use
Commodes covered if patient is confined to bed or room. 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 the patient to his home in a case where there are no toilet facilities may be equated to room confinement. Moreover, payment may also be made if a patient's medical condition confines him to a floor of his home and there is no bathroom located on that floor (see Hospital Beds for definition of “bed confinement”).
Communic-Aid deny—convenience item
Communicator deny—convenience item in home setting
Cos-Medic Automasseur deny—(see Massage Devices)
Crutches covered if patients' condition impairs ambulation
Cushion Lift Power Seat (see Seat Lift)
Dehumidifiers (room or central heating system type) deny—environmental control equipment; not primarily medical in nature
Den-Mat (see Mattress). Payment should be based on amount payable for ordinary hospital bed mattress
DePuy Flote Bed (see Alternating Pressure Pads and Mattresses)
DePuy Flotation Mattress (see Alternating Pressure Pads and Mattresses)
Dialysis Equipment (see Artificial Kidney)
Diapulse Machine deny—(see Diathermy Machines)
Diathermy Machines (standard and pushed wave types) deny—inappropriate for home use
Digital Electronic Pacemaker Monitor covered when prescribed by a physician for a patient with a cardiac pacemaker
Disposable Sheets and Bags deny—nonreusable disposable supplies
Dual King Bed deny—(see Beds-Lounge)
Ease-O-Matic Bed Spring deny—(see Beds-Lounge)
Eaton E-Z Bath deny—(see Bathtub Seats)
Elastic Stockings deny—nonreusable supply, not rental-type items
Electra-Rest Bed deny—(see Beds-Lounge)
Electric Air Cleaners deny—(see Air Cleaners)
Electric Hospital Beds (see Hospital Beds)
Electrocardiocorder deny—not covered as durable medical equipment—(home use may be covered only as a hospital or physician diagnostic service)
Electrostatic Machines deny—(see Air Cleaners and Air Conditioners)
Elevators deny—convenience item; not primarily medical in nature
Emesis Basins deny—physician instrument
Esophageal Dilator deny—physician instrument
Exercise Equipment deny—not primarily medical in nature
Exercycle deny—exercise equipment; not primarily medical in nature
Face Masks (oxygen) covered as equipment accessory (HI 00610.230)
Face Masks (surgical deny—nonreusable disposable items
Flowmeter (see Medical Oxygen Regulators)
Fluidic Breathing Assistor covered where there is need for IPPB device but oxygen is not required (There are no medical indications for simultaneous home use of the assistor and an IPPB machine)
Franklin Electric Hospital Bed (see Hospital Beds)
Gatchboard deny—(see Bedboards)
Gel Flotation Pads and Mattresses (see Alternating Pressure Pads and Mattresses)
Glideabout Chair (see Rollabout Chairs)
Grab Bars deny—self-help device, not primarily medical in nature
Grant Alternating Pressure Pads (see Alternating Pressure Pads and Mattresses)
Hand-D-Jet deny—(see Portable Whirlpool Pumps)
Hand-E-Vent (see IPPB Machines)
Heating and Cooling Plants deny—environmental control equipment, not primarily medical in nature
Heating Pads covered if the contractor'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 the contractor'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
Hemodialysis Equipment (see Artificial Kidney)
Honeywell Air Purifier deny—(see Air Cleaners and Air Conditioner)
Hospital Beds
1. General covered if patient is bed confined and the contractor's medical staff determines patient's condition necessitates positioning the body (especially the head, chest, legs, and feet) in a way which would not be feasible in an ordinary bed or attachments are required which could not be used on an ordinary bed.1
NOTE: The term “bed confined” indicates that the patient's medical condition is of such severity that he is confined to bed, although not necessarily 100 percent of the time.
2. Electrically Elevates and lowers head and foot covered if the contractor's physician determines patient's condition is such that frequent change in body position is necessary and/or there may be an immediate need for a change in position (i.e., no delay in change can be tolerated) and the patient himself can effect these adjustments (by operating the controls). In all cases, verify the medical necessity for this type of hospital bed with medical staff.
3. Franklin Electric Hospital Bed full payment for this bed should not be made. Base payment on whichever hospital bed above satisfies the patient's medical needs. In all cases, verify medical necessity for such features with medical staff.
Hoyer Lift (see Patient Lifts)
Humidifiers (oxygen) (see Oxygen Humidifiers)
Humidifiers (room or central heating system types) deny—environmental control equipment; not medical in nature
Hydraulic Lift (see Patient Lifts)
Hydrocollator Heating Unit deny—not essential to administration of moist heat therapy, serves no clearly identifiable medical purpose
Hydrocollator Steam Packs effective June 15, 1978, these packs are covered under same condition as a heating pad. Carriers limit payment to amount which would be payable for ordinary heating pad.
Hydro Jet Whirlpool Bath deny—see Portable Whirlpool Pumps)
Incontinent Pads deny—nonreusable supply; hygienic item
Infusion Pumps covered if contractor's medical staff verifies the appropriateness of the therapy and of the prescribed pump for home use. (Physician's prescription must specify that he will be supervising its use in connection with a course of treatment.)
Inhalators covered if patient's ability to breathe is severely impaired
IPPB Machines covered if patient's ability to breathe is severly impaired
Iron Lungs covered if patient has respiratory paralysis
Irrigating Kit deny—nonreusable supply; hygienic equipment
ITI Mechanical Percussor (See Percussors)
Jacuzzi Portable Whirlpool Pump deny—(see Portable Whirlpool Pumps)
Jobst Pneumatic Appliances covered if the pneumatic appliance(s) has been prescribed for use with a medically necessary Jobst Pneumatic Compressor
Jobst Pneumatic Compressor (lymphedema pump) (see Lymphedman Pumps—nonsegmental therapy type)
Jobst Pressure Gradient Fabric Supports deny—nonreusable supplies, not rental-type item
Jobst Stockings and Support Hose deny—(see Jobst Pressure Gradient Fabric Supports)
Lakematic Power Chair (see Wheelchairs)
Lambs Wool Pads deny—nonreusable supplies, not rental-type item
Lattoflex Spring-Base deny—not a hospital bed; comfort or convenience item; not primarily medical in nature
LC-3 Oxygen System deny—institutional oxygen system; not a rental-type item
Leotards deny—(see Pressure Leotards)
Lif-O-Gen Tanks (see Portable Oxygen Systems)
Limb-O-Cycle deny—(exercise equipment; not primarily medical in nature
Linde Oxygen Walker system (see Portable Oxygen Systems)
Lumex Chair Table (see Rollabout Chairs)
Lymphedema Pumps (nonsegmental therapy type) covered if patient had intractable edema of the extremities
Lymphedema Pumps (segmental therapy type) deny—institutional or physician equipment; inappropriate for home use
Madasphere Portable Oxygen Unit (see Portable Oxygen Systems)
Magic-Dailey Bedpan covered when hospital-type bed pan is required. Limit payment of amount which would be payable for ordinary hospital-type bed pan
Marx Oxygen Concentrator (Model 600) covered if patient's ability to breathe is severely impaired.
Masks (oxygen) covered
Masks (see Face Masks)
Massage Devices deny—considered comfort items not generally accepted by the medical profession as either medically indicated or effective.
Mattress covered only where hospital bed is medically necessary. (Separate charge for replacement mattress should not be allowed where hospital bed with mattress is rented.)
Maxi-Myst covered if patient's ability to breathe is severely impaired
McKune Whirlpool Bath deny—(see Portable Whirlpool Pumps)
Mecalift (see Patient Lifts)
Medcolator deny—inappropriate for home use
Medco-Minalator deny—inappropriate for home use
Medco-Sonolator Twin deny—inappropriate for home use
Medco-Therm Muscle
Stimulator
deny—inappropriate for home use
Medic-Ease Mattress covered under same condition as alternating pressure pad or mattress. Base reimbursement on less expensive item if that satisfies patient's need
Medical Oxygen Regulators covered if patient's ability to breathe is severely impaired
Micronaire Environmental
Control
deny—(see Air Cleaners and Air Conditioners)
Mobile Geriatric Chair (see Rollabout Chairs)
Mobile Monomatic Sanitation System deny—institutional type of hygienic equipment; not necessary and reasonable for home use
Moore Wheel deny—convenience item; exercise equipment; not primarily medical in nature
Motorized Wheelchairs (see Wheelchairs)
Muscle Stimulator Burdick MS-300 deny—inappropriate for home use
Myoflex Muscle Stimulator deny—produced no demonstrable therapeutic effect
Nebulizers covered if patient's ability to breathe is severely impaired
Niagara Massage Pillow deny—comfort or convenience item; not primarily medical in nature
Niagara Thermo-Cyclopad deny—not generally accepted by medical profession as being therapeutically effective
Nolan Bath Chair deny—comfort or convenience item; hygienic equipment, not primarily medical in nature
Oaks Controller Unit deny—self-help device; institutional-type equipment
Osci-Lite covered under same conditions as Heat Lamps. Limit payment to amount which would be payable for ordinary heat lamp
Oscillating Beds deny—institutional equipment—inappropriate for home use
Overbed Tables deny—convenience item; not primarily medical in nature
Oxycane (see Portable Oxygen Systems)
Oxygen covered if the oxygen has been prescribed for use in connection with medically necessary durable medical equipment
Oxygen Humidifiers covered if a medical humidifier has been prescribed for use in connection with medically necessary durable medical equipment for purposes of moisturizing oxygen
Oxygen Regulators (Medical) (see Medical Oxygen Regulators)
Oxygen Tank Noncovered except as an incidental cost of providing oxygen. It is not medical equipment, serves neither a therapeutic nor diagnostic function.
Oxygen Tents covered if patient's ability to breathe is severely impaired.
Pace Trac (see Digital Electronic Pacemaker Monitor)
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., a walker, satisfies the patient's need
Patient Lifts covered if contractor's physician determines patient's condition in such that periodic movement is necessary to effect improvement or to arrest or retard deterioration in his condition
Percussion pac (see Percussors)
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 has received appropriate training by a physician or therapist, and no one competent to administer manual therapy is available.
Portable Oxygen Systems
1. Regulated (adjustable flow rate) covered under certain circumstances. Contractor refers all claims to its medical staff for a determination
2. Preset (flow rate not adjustable) deny
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
Portable Whirpool Pumps deny—does not primarily and customarily serve a therapeutic purpose, generally used for soothing or comfort purposes
Port-O-Matic (oxygen unit) (see Portable Oxygen Systems)
Postural Drainage Boards covered if patient has a chronic pulmonary condition
Posture Support Chairs (see Seat Lift)
Posturpedic Mattress (see Mattress)
Preset Portable Oxygen Units deny—emergency, first-aid, or precautionary equipment; essentially not therapeutic in nature.
Pressure-Eze-Pad (see Alternating Pressure Pads and Mattresses)
Pressure Leotards deny—nonreusable supply; not rental-type item
Pulse Tachometer deny—nonreasonable or necessary for monitoring pulse of homebound patient with or without a cardiac pacemaker
Quad-Canes (see Walkers)
Raised Toilet Seats deny—convenience item; hygienic equipment; not primarily medical in nature
Recliner with Elevating Seat (see Seat Lifts. Payment for this item should be limited to the amount payable for a seat lift without the reclining chair features)
Renal Dialysis Equipment (see Artificial Kidney)
Respirators covered if the contractor's medical staff determines that the apparatus specified in the claim is medically required and appropriate for home use without technical or professional supervision
Restorator deny—exercise equipment; not primarily medical in nature
Rollabout Chairs covered if contractor's medical staff determines that the patient's condition is such that there is a medical need for this item and it has been prescribed by the patient's physician in lieu of a wheelchair. Coverage is limited to those rollabout chairs having casters of at least 5 inches in diameter and specially designed to meet the needs of ill, injured, or otherwise impaired individuals; coverage is not intended to extend to 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 or treatment of ill or injured persons.
Safety Grab Bars deny—(see Grab Bars)
Sauna Baths deny—not medical in nature; primarily used to improve appearance or for comfort purposes.
Schmidt Bed Bath deny—(see Bed Baths)
Seat Lift or Tilt covered under certain conditions. Refer all claims to medical staff for this determination
Select-A-Rest deny—see Beds-Lounge)
Selectronair deny—(see Air Cleaners and Air Conditioners)
Sigmamotor Mobile Infusion Pump (see Infusion Pumps) this pump is suitable for home use
Sitz Bath covered if the contractor'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
S.O.S. Emergency Oxygen Inhalator (see Portable Oxygen Systems)
Spare Deionization Supply Tanks deny—conveinence or precautionary
Spare Tanks of Oxygen deny—convenience or precautionary supply
Spectroware Machine deny—(see Diathermy Machines)
Speech Teaching Machines deny—educational equipment; not primarily medical in nature
Sphygmomanometer with cuff covered if prescribed by physician for use as part of a home dialysis delivery system
Sphygmostat same as above
Stairglide deny—(see Elevators)
Stairway Elevators deny—(see Elevators)
Standing Table deny—convenience item; not primarily medical in nature
Stethoscope covered if prescribed by physician for use with a sphygmomanometer as part of a home dialysis delivery system
Stryker Floation Pads and Mattresses (see Alternating Pressure Pads and Mattresses)
Suction Machine covered if the contractor's medical staff determines that the machine specified in the claim is medically required and appropriate for home use without technical or professional supervision
Superpulse Machine deny—(see Diathermy Machines)
Surgi-Bed deny—institutional equipment, inappropriate for home use
Surgical Leggings deny—nonreusable supply; not rental-type item
Telemedic II deny—not covered as durable medical equipment (home use may be covered only as an out-patient hospital or physician diagnostic service)
Telephone Alert Systems deny—these are emergency communications systems and do not serve a diagnostic or therapeutic purpose.
Telephone Arms deny—convenience item; not medical in nature
Therabath deny—(see Portable Paraffin Bath Units)
Theramatic Machines deny—(see Diathermy Machines)
Thermo-Jet deny—(see Portable Whirlpool Pumps)
Toilet Seats deny—not medical equipment
Traction Equipment covered if patient has orthopedic impairment requiring traction equipment which prevents ambulation during the period of use. (Devices usable during ambulation, e.g., cervical traction collar, may be covered under the brace provision)
Translift Chair deny—institutional equipment
Trapeze Bars covered if patient is bed confined and there is need to sit up because of a respiratory condition or a need to change body position for other medical reasons, or to get in and out of bed (See Hospital Beds for definition of “bed confined”)
Treadmill Exerciser deny—exercise equipment not primarily medical in nature
Tub Chair deny—(see Bathtub Seats)
Tubo-Jet (see Portable Whirlpool Pumps)
Ultraviolet Cabinet covered for selected patients with generalized intractable psoriasis—Using appropriate consultation, the contractor should determine whether medical and other factors justify treatment at home rather than at alternative sites, e.g., out-patient department of a hospital
Urinals (autoclavable hospital type) covered if patient is bed confined—(see Hospital Beds for definition of “bed Confined”)
Vaporizers covered if patient has a respiratory illness
Vasculaider Bed deny—(see Oscillating Beds)
Vasoscillating Bed deny—(see Oscillating Beds)
Walkers covered if patient's condition impairs ambulation
Water and Pressure Pads and Mattresses (see Alternating Pressure Pads and Mattresses)
Watkins Chronofusor (infusion pump) (see Infusion Pumps) this pump is suitable for home use
Wheel-O-Vator deny—(see Elevators)
Wheelchairs covered if patient's condition is such that without the use of a wheelchair he would be bed or chair confined. An individual may qualify for a wheelchair and still be bed confined (see Hospital Beds for a definition of “bed confined”)
Power operated wheelchairs and wheelchairs with other special features covered if patient's condition is such that a wheelchair is medically necessary and the patient is unable to operate the wheelchair manually. Any claim involving a power wheelchair or a wheelchair with other special features should be referred for medical consultation since payment for the special features is limited to those which are medically required because of the patients condition
NOTE: A power-operated vehicle that may appropriately be used as a wheelchair can be covered.
Whirl-a-Bath deny—(see Portable Whirlpool Pumps)
Whirl-O-Matic deny—(see Portable Whirlpool Pumps)
Whilepool Bath Equipment (standard) covered if patient is homebound and has a 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)

1 A variable-height feature (mechanical or electrical, often available in hospital beds, serves only a convenience function and is without medical relevance to the patient's condition. A charge for this feature should not be recognized. However, where the contractor has determined that the hospital bed required by the patient was not available in the locality without this feature, it may recognize the total reasonable charge for such bed.


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HI 00610.300 - Examples of Durable Medical Equipment Covered and Not Covered - 02/09/1993
Batch run: 02/09/1993
Rev:02/09/1993