(Medicare Benefit Policy Manual)

Contractors do not get involved in issues relating to ownership or title of property.  110.5 - Incurred Expense Dates for Durable Medical Equipment  (Rev. 1, 10- 01-03) A3-3113.7.B, HO -235.7.B, B3- 3011  The date of service on the claim must be the date that the beneficiary or authorized representative received the DMEPOS item.  If the date of delivery is not specified on the bill, the contractor should assume, in the absence of evidence to the contrary, t hat the date of purchase was the date of delivery.   For mail order DMEPOS items, the date of service on the claim must be the shipping date.  The date of service on the claim must be the date that the DMEPOS item(s) was received by the nursing facility if the supplier delivered it or the shipping date if the supplier utilized a delivery/shipping service.   An exception to the preceding statements concerning the date of service on the claim occurs when items are provided in anticipation of discharge from a hospital or nursing facility.  If a DMEPOS item is delivered to a patient in a hospital up to two days prior to discharge to home and it is for the benefit of the patient for purposes of fitting or training of the patient on its use, the supplier should bill the date of service on the claim as the date of discharge to home and should use POS=12.  See the Medicare Program Integrity Manual, Chapter 5, Items and Services Having Special DME Review Considerations, for additional information pertaining to the date of service on the claim.  Also see the Medicare Claims Processing Manual, Chapter 20, Du rable Medical Equipment, Surgical dressings and Casts, Orthotics and Artificial Limbs, and Prosthetic Devices, for additional DME billing and claims processing information.   110.6 - Determining Months for Which Periodic Payments May Be Made for Equipment Used in an Institution  (Rev. 1, 10- 01-03) A3-3113.7.D, HO -235.7.C   If a patient uses equipment subject to the monthly payment rule in an institution, which does not qualify as his or her home, the used months during which the beneficiary was institutionalized are not covered.   110.7 - No Payment for Purchased Equipment Delivered Outside the United States or Before Beneficiarys Coverage Began  (Rev. 1, 10- 01-03) A3-3113.7.C   In the case of equipment subject to the lump sum payment rules, the beneficiary must have been in the United States and must have had Medicare coverage at the time the item was delivered.  Therefore, where an item of durable medical equipment paid for as a  lump sum was delivered to an individual outside the United States or before his or her coverage period began, the entire expense of the item would be excluded from coverage.  Payment cannot be made in such cases even though the individual later uses the i tem inside the United States or after his or her coverage begins.   If the individual is outside the U.S. for more than 30 days and then returns to the U.S., the DME MAC determines medical necessity as in an initial case before resuming payments.   110.8  DMEPOS Benefit Category Determinations  (Rev.  12171, Issued:08-03-2023, Effective:09- 04-2023, Implementation: 09-04-2023)  Whether or not an item or service falls under a Medicare benefit category, such as the Medicare Part B benefit category for DME, is a necessary step in determining whether an item may be covered under the Medicare program and, if applicable, what statutory and regulatory payment rules apply to the items and services. If the item is excluded from coverage by the Act or does not fall within the scope of a defined benefit category, the item cannot be covered under Medicare Part B.   Medicare Durable Medical Equipment, Prosthetic Devices, Prosthetics, Orthotics and Supplies (DMEPOS) benefit category determinations established on or after September 26, 2022, in accordance with the procedures at 42 CFR 414.114 and 414.240, are listed below. These procedures consider public consultation furnished at public meetings and in writing in accordance with requirements for new DME items by section 531(b) of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) (Pub L. 106-554). This section is a quick reference tool for the benefit categories of items and services evaluated using the procedures described above. The section is organized alphabetically by the categories of items and services and then by the benefit category determi nation with effective date.   Special note: the benefit category and payment rules for items and services that are assigned to an existing HCPCS code(s) are determined by the benefit category and payment rules for that HCPCS code(s). More information on the benefit category final determinations for items and services reviewed using the process described above is available at https://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo/HCPCSPublicMeetings.  DMEPOS Benefit Category Determinations    Item  Benefit Category Determination   Benefit Category  Effective Date  Addition, Endoskeletal  Knee -Shin System, 4 Bar Linkage or Multiaxial, Fluid Swing and Stance Phase Control   Artificial Leg --This item is a microprocessor -controlled knee added to a prosthetic leg that utilizes a 4 -bar geometry with hydraulic control of both stance and swing phases of gait.  10-1-22 Addition to Lower Extremity Prosthesis, Endoskeletal Knee Disarticulation, Above Knee, Hip Disarticulation, Positional Rotation Unit  Artificial Leg --This item is added to a prosthetic leg and provides 360- degree rotation of the prosthetic limb to accommodate specific environmental situations.   10-1-22 Powered Pressure Reducing Underlay/pad, Alternating, With Pump  DME --Decubitus care equipment which uses alternating turning pressure pad placed under the mattress rather than on top of the mattress.  10-1-22 Cranial Electrotherapy Stimulation System  DME --These  devices utilize a microcurrent to deliver proprietary low -level electrical signals trans cranially to treat insomnia, depression, anxiety, and pain.  10-1-22 Disposable Collection and Storage Bag for Breast Milk, Any Size  No DMEPOS Benefit Category --There is no DMEPOS benefit category for disposable supplies. Also, electric breast 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  10-1-22 Distal Transcutaneous Electrical Nerve Stimulator, Stimulates Peripheral Nerves of the Upper Arm  No DMEPOS Benefit Category --Minimum lifetime requirement of at least three years not met.  10-1-22 Electronic Positional Obstructive Sleep Apnea Treatment  Equipment, With Sensor DME --These items are classified as DME if FDA clearance expressly states it is for the treatment of positional obstructive sleep apnea and is not clinically indicated or marketed for anti -snoring or other non-medical uses and all other requirements for classification as DME in accordance with 414.202 are met .  10-1-22 Enema Tube, With or Without Adapter  No DMEPOS Benefit Category --These items cannot withstand repeated use and are therefore not DME. Rectal catheters or tubes are not prosthetic devices because they do not replace all or part of an internal body organ or all or part of the function of a permanently inoperative or malfunctioning internal body organ.   10-1-22 Electrical stimulator supplies (external) for use with implantable neurostimulator, per month Prosthetic Device These items are accessories for n euromodulation systems indicated for pain management in adults who have severe intractable pain of peripheral nerve origin.  4-1-23  Expiratory positive airway pressure intranasal resistance valve No DMEPOS Benefit Category -- These are single-patient, reusable expiratory positive airway pressure (EPAP) devices for the treatment of obstructive sleep apnea. These single- patient items cannot withstand repeated use and therefore are not DME.  4-1-23  External Upper Limb Tremor Stimulator of the Peripheral Nerves of the Wrist  DME --These devices deliver electrical stimulation to the nerves in the wrist to stimulate the peripheral nervous system for the treatment of essential tremors.  10-1-22 Foot Adductus Positioning Device, Adjustable Leg Brace --These are foot positioning devices that stabilize the heel in the heel cage and the rest of the foot in the device while applying corrective pressures to the midfoot, thereby realigning the malformed pediatric foot. This is considered to be an alternative to serial casting. The devices treat new borns with semiflexible and rigid metatarsus adductus/varus, as well as flexible metatarsus adductus/varus that does not respond to stretching.  10-1-22 Hydrophilic, Dual Focus Contact Lens  No DMEPOS Benefit Category --Contact lens used for the correction of myopic ametropia and for slowing the progression of myopia in children. These lenses do not qualify as prosthetic devices under any of the categories for prosthetic lenses under section 120.B of chapter 15 of the Medi care Benefit Policy Manual.  10-1-22 Hydrophilic, Spherical Contact Lens with Photochromic Additive  Prosthetic Device --Refractive lenses are covered as prosthetic lenses under the benefit category for prosthetic devices when they are used to restore the vision normally provided by the natural lens of the eye of an individual lacking the organic lens beca use of surgical removal or congenital absence. Covered diagnoses are limited to pseudophakia (condition in which the natural lens has been replaced with an artificial intraocular lens [IOL]), aphakia (condition in which the natural lens has been removed but there is no IOL), and congenital aphakia. Lenses provided for other diagnoses will be denied as noncovered. Coverage may be limited to one pair of eyeglasses or contact lenses. Because coverage of refractive lenses is based upon the prosthetic device ben efit category, there is no coverage for frames or lens add -on codes unless there is a covered lens(es). Tinted lenses, including photochromatic lenses, used as sunglasses, which are prescribed in addition to regular prosthetic lenses to a pseudophakic bene ficiary, will be denied as noncovered.   10-1-22 Indwelling intraurethral drainage device with valve, patient inserted  Prosthetic Device The device is a urethral insert with a valve for bladder drainage. The intraurethral device replaces the function of a permanently inoperative bladder.  4-1-23  Knee Ankle Foot Device, Any Material, Single or Double Upright, Swing and Stance Phase Microprocessor Control with Adjustability, Includes All Components (e.g., Sensors, Batteries, Charger), Any Type Activation, with or without Ankle Joint(s), Custom Fabri cated  Leg Brace --Rigid device used for the purpose of supporting a weak or deformed leg.   10-1-22 Low Frequency Ultrasonic Diathermy Treatment Device for Home Use  No DMEPOS Benefit Category --Minimum lifetime requirement of at least three years not met. These items are not the standard pulses wave types of diathermy machines referenced in section 280.1 of chapter 1, part 4 of the National Coverage Determinations Manu al. However, the equipment must be able to be rented and used by multiple patients for a minimum of three years in order to be classified as DME.   10-1-22 Mechanical Allergen Particle Barrier/Inhalation Filter, Cream, Nasal, Topical  No DMEPOS Benefit Category --Minimum lifetime requirement of at least three years not met.   10-1-22 Molecular diagnostic test reader, nonprescription self -No DMEPOS Benefit Category -- In vitro diagnostic medical device for analyzing 4-1-23  administered and self -collected use, fda approved, authorized or cleared  specimens in the home collected with the single -use cartridges.  Neuromuscular electrical stimulator (nmes), disposable, replacement only  No DMEPOS Benefit Category  These single -patient items cannot withstand repeated use and therefore are not DME.    4-1-23