Page 133 - Medicare Benefit Policy Manual

DMEPOS Benefit Category Determinations

Item Benefit Category Determination

Addition, Endoskeletal Artificial Leg--This item is a microprocessor-controlled knee
Knee-Shin System, 4 Bar added to a prosthetic leg that utilizes a 4-bar geometry with
Linkage or Multiaxial, hydraulic control of both stance and swing phases of gait.
Fluid Swing and Stance Final determination established on 09-26-22.
Phase Control

Addition to Lower Artificial Leg--This item is added to a prosthetic leg and
Extremity Prosthesis, provides 360-degree rotation of the prosthetic limb to
Endoskeletal Knee accommodate specific environmental situations.
Disarticulation, Above Final determination established on 09-26-22.
Knee, Hip Disarticulation,
Positional Rotation Unit

Automated Lateral Turning DME--Decubitus care equipment which uses alternating
System: Positioned pressure pad placed under the mattress rather than on top of
Beneath Patient's Mattress the mattress. Final determination established on 09-26-22.

Cranial Electrotherapy DME--These devices utilize a microcurrent to deliver
Stimulation System proprietary low-level electrical signals trans cranially to treat
insomnia, depression, anxiety, and pain.
Final determination established on 09-26-22.

Disposable Collection and No DMEPOS Benefit Category--There is no DMEPOS
Storage Bag for Breast benefit category for disposable supplies. Also, electric breast
Milk, Any Size pumps are not classified as DME. Therefore, disposable
supplies used with these items would not fall under a
DMEPOS benefit category. With regard to manual breast
pumps and related supplies, the Medicare Administrative
Contractor processing claims for these items would
determine whether or not the pump is DME on a claim by
claim basis.
Final determination established on 09-26-22.

Distal Transcutaneous No DMEPOS Benefit Category--Minimum lifetime
Electrical Nerve requirement of at least three years not met.
Stimulator, Stimulates Final determination established on 09-26-22.
Peripheral Nerves of the
Upper Arm

Electronic Positional DME--These items are classified as DME if FDA clearance
Obstructive Sleep Apnea expressly states it is for the treatment of positional
obstructive sleep apnea and is not clinically indicated or