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Disposable Medical Supplies/Durable Medical Equipment, 4th edition
Apollo Managed Care Consultants, May 2011, Pages: 162
Durable medical equipment (DME) may not be a covered benefit unless the individual or their employer has purchased a DME rider. However, certain DME is integral to the treatment (surgical and non-surgical) of many conditions (e.g., orthopedic casts, supportive and functional braces, splints) and are covered even though a DME benefit is not delineated in the Certificate of Coverage or an associated rider.
Definition of Durable Medical Equipment
For purposes of coverage durable medical equipment is equipment which:
1) Can withstand repeated use, and
2) is primarily and customarily used to service a medical purpose, and
3) generally is not useful to a person in the absence of illness or injury and
4) is appropriate for use in the home.
This report covers hundreds of specific review criteria for supply and DME Items, plus an alpha list with explanatory recommendation for the basis to deny or approve payment, based on the usual coverage of 'medical necessity' determinations. The report includes references and web links.
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