HI 00610.200 Definition of Durable Medical Equipment
Durable medical equipment is equipment which can withstand repeated use, see A. below, and is primarily and customarily used to serve a medical purpose, see B. below, and generally is not useful to a person in the absence of an illness or injury, see B. below, and is appropriate for use in the home.
An item is considered durable if it can withstand repeated use, i.e., the type of item which could normally be rented. Medical suppliers of an expendable nature such as incontinent pads, lambs wool pads, catheters, ace bandages, surgical face masks, irrigating kits, sheets and bags are not considered “durable” within the meaning of the definition. There are other items which, although durable, may fall into other coverage categories such as braces, prosthetic devices, artificial arms, legs, and eyes.
B. Medical equipment
Medical equipment is equipment which is primarily and customarily used for medical purposes and is not generally useful in the absence of illness or injury.
1. Equipment presumptively medical
Items such as hospital beds, wheelchairs, hemodialysis equipment, iron lungs, respirators, intermittent positive pressure breathing machines, medical regulators, oxygen tests, crutches, canes, trapeze bars, walkers, inhalators, nebulizers, commodes, suction machines and traction equipment presumptively constitute medical equipment.
(Although hemodialysis equipment is a prosthetic device and DME it also has a separate coverage provision of its own and is reimbursed under that provision.)
NOTE: There is a wide variety in types of respirators and suction machines. The carrier's medical staff determines whether the apparatus specified in the claim is appropriate for home use.
2. Equipment presumptively nonmedical
Equipment which is primarily and customarily used for a nonmedical purpose may not be considered “medical” equipment for program payment even though the item has some remote medically related use. For example, for a cardiac patient, an air conditioner might possibly be used to lower room temperature to reduce fluid loss in the patient and to restore an environment conducive to maintenance of the proper fluid balance. Nevertheless, because the primary and customary use of an air conditioner is a nonmedical one, the air conditioner cannot be deemed to be medical equipment for which payment can be made.
Other devices and equipment used for environmental control or to enhance the environmental setting in which the beneficiary is placed are not considered covered DME. These include room heaters, humidifiers, dehumidifiers, and electric air cleaners. Equipment which basically serves comfort or convenience functions or is primarily for the convenience of a person caring for the patient such as elevators, stairway elevators, posture chairs, and cushion lift chairs do not constitute medical equipment. Similarly, physical fitness equipment, e.g., an exercycle; first-aid or precautionary-type equipment, e.g., preset portable oxygen units; self-help devices, e.g., safety grab bars; and training equipment, e.g., speech teaching machines and braille training texts, are considered nonmedical in nature.
3. Special exception items
Specified items of equipment may be covered under certain conditions even though they do not meet the definition of DME because they are not primarily and customarily used to serve a medical purpose and/or are generally useful in the absence of illness or injury. These items are covered when it is established that they serve a therapeutic purpose in an individual case and include:
Gel pads and pressure and water mattresses (which generally serve a preventive purpose) when prescribed for a patient who had bed sores or there is medical evidence indicating that he is highly susceptible to such ulceration; and
Heat lamps for a medical rather than a soothing or cosmetic purpose e.g., when the need for heat therapy has been established.
In establishing medical necessity (HI 00610.210) for the above items, the evidence must show that the item is included in the physician's course of treatment and a physician is supervising its use.
Note: The above items represent special exceptions and no extension of coverage to other items should be inferred.