Latest Review Date:  January 2024

Category:  Administrative                                                    

POLICY:

Repair of durable medical equipment and external prosthetic devices may be considered medically necessary when all the following are met:

• The individual owns the equipment or prosthesis; and
• The required repairs are not the result of malicious damage, culpable neglect, or wrongful disposition if the equipment; and
• The expense of the repairs does not exceed the expense of purchasing a new piece of equipment or prosthesis; and
• The equipment or external prosthesis is not currently covered by warranty.

If the individual owned DME is being repaired, up to one month’s rental for that piece of durable medical equipment may be considered medically necessary.

Payment is based on the type of replacement device that is provided but will not exceed the rental allowance for the equipment that is being repaired.

DESCRIPTION OF PROCEDURE OR SERVICE:

Durable medical equipment (DME) is equipment which:

• Can withstand repeated use;
• Used mainly for a medical purpose rather than for comfort or convenience;
• Generally, is not useful to a person in the absence of an illness or injury;
• Related to a medical condition and prescribed by a physician for use in the home;
• Is appropriate for use in the home; and
• Is determined to meet medical criteria for coverage to diagnose or treat an illness or injury, help a malformed part of the body or work well, help an impaired part of the body to work within its functional parameters, or keep a condition from becoming worse.

Repairs to equipment owned by a patient may be required to make the DME operational after damage or wear.

Prosthetics

Prosthetic appliances are devices that are designed to replace all or part of a permanently inoperative, absent, or malfunctioning body organ. 

External prosthetic devices, which are worn as an anatomic supplement, are used to replace non-functioning or absent body parts. Examples of external prosthetic devices include artificial limbs, removable artificial eyes, external breast prostheses or prosthetic bras for post mastectomy patients, external pacemakers and electronic speech aids for post-laryngectomy patients.

Orthotics

An orthotic (orthosis) is a rigid or semi-rigid orthopedic appliance or device that is used to support, align, prevent or correct deformities, protect a body function, improve the function of movable body parts or to assist a dysfunctional joint. Orthotics may also redirect, restrict or prevent motion of an impaired body part. An orthotic must be used for therapeutic support, protection, restoration, or function of an impaired body part and be used in the treatment of an illness or injury.

KEY WORDS:

Durable medical equipment, DME, repair, replacement, external prosthetic devices, prosthetic repair, orthotic, orthotic repair

APPROVED BY GOVERNING BODIES:

Not applicable.

BENEFIT APPLICATION:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP contracts: Special benefit consideration may apply.  Refer to member’s benefit plan.

CURRENT CODING:

HCPCS Codes:

POLICY HISTORY:

Medical Policy Group, March 2009 (2)

Medical Policy Administration Committee May 2009

Available for comment May 12-June 24, 2009

Medical Policy Group, June 2009 (2)

Medical Policy Administration Committee, July 2009

Medical Policy Group, June 2015 (6):  Updates to Coding and Benefit Application; no change in policy statement.

Medical Policy Group, July 2017 (6): Updated Description, Coding and Key Words. No change in policy statement.

Medical Policy Group, April 2020 (6): Updates to Description, Coding (added L4205/L4210) and Key Words (prosthetic repair, orthotic, orthotic repair). No change to policy intent.

Medical Policy Group, March 2021 (6): Reviewed by consensus. No change in policy intent.

Medical Policy Group, April 2022 (6): Reviewed by consensus. No change in policy intent.

Medical Policy Group, January 2023 (6): Reviewed by consensus. No change in policy intent.

Medical Policy Group, January 2024 (6): Updates to Benefit Application. No change to policy intent.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;

3. The technology must improve the net health outcome;

4. The technology must be as beneficial as any established alternatives;

5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and

2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and

3. Not primarily for the convenience of the patient, physician or other health care provider; and

4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.