Page 124 - Medicare Benefit Policy Manual

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 would be covered when it is clearly established that they serve a therapeutic
purpose in an individual case and would include:

a. 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 they are highly susceptible to
such ulceration; and

b. Heat lamps for a medical rather than a soothing or cosmetic purpose, e.g.,
where the need for heat therapy has been established.

In establishing medical necessity 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.

C. Necessary and Reasonable

Although an item may be classified as DME, it may not be covered in every instance.
Coverage in a particular case is subject to the requirement that the equipment be
necessary and reasonable for treatment of an illness or injury, or to improve the
functioning of a malformed body member. These considerations will bar payment for
equipment which cannot reasonably be expected to perform a therapeutic function in an
individual case or will permit only partial therapeutic function in an individual case or
will permit only partial payment when the type of equipment furnished substantially
exceeds that required for the treatment of the illness or injury involved.

See the Medicare Claims Processing Manual, Chapter 1, “General Billing Requirements;”
§60, regarding the rules for providing advance beneficiary notices (ABNs) that advise
beneficiaries, before items or services actually are furnished, when Medicare is likely to
deny payment for them. ABNs allow beneficiaries to make an informed consumer
decision about receiving items or services for which they may have to pay out-of-pocket
and to be more active participants in their own health care treatment decisions.

1. Necessity for the Equipment

Equipment is necessary when it can be expected to make a meaningful contribution to the
treatment of the patient’s illness or injury or to the improvement of his or her malformed
body member. In most cases the physician’s prescription for the equipment and other