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HealthPartners

Coverage criteria policies

Durable medical equipment and prosthetics

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for some durable medical equipment (DME) items. Please refer to the specific policy for coverage criteria for the requested item.

Prior authorization is not required for DME and supplies that are included in a facility’s per diem.

Coverage

Durable medical equipment (DME) and prosthetics are generally covered subject to the indications listed below and per your plan documents.

Equipment and services are covered as described below and in your member contract:

  1. DME and orthotic benefits, including certain disposable supplies, enteral feedings and the following diabetic supplies and equipment: glucose monitors, insulin pumps, syringes, blood and urine test strips and other diabetic supplies as deemed medically appropriate and necessary, for members with gestational, Type I or Type II diabetes. No more than a 90-day supply will be covered and dispensed at a time.
  2. DME and supplies must be obtained from, or repaired by, HealthPartners approved vendors.
  3. DME and orthotics are limited by the following:
    1. All covered DME items should be the acceptable and standard model, considering the member’s medical condition. If a member requests an alternative item/part, which is safe and effective, HealthPartners may cover the cost up to the cost of the acceptable standard model.
    2. The total payment for DME equipment to address a need will not exceed the cost of the standard equipment or service that is effective and medically necessary.
    3. We reserve the right to determine if an item will be approved for rental vs. purchase.
  4. For prosthetic benefits, other than hair prostheses (i.e., wigs) for hair loss resulting from alopecia areata and oral appliances for cleft lip and cleft palate, payment will not exceed the cost of an alternate piece of equipment or service that is effective and medically necessary. Check your plan documents for limits that may apply.
  5. Artificial Eye (eye prosthesis) is covered. Coverage Includes polishing and adjustments.
  6. Coverage is limited to one prosthetic item, unless bilateral prosthesis is recommended and meets medical necessity for both sides. DME items will not be approved which are primarily educational in nature, or for hygiene, vocation, comfort, convenience or recreation.
  7. Covered services and supplies are based on established medical policies, which are subject to periodic review and modification by the Medical or Dental Directors. These medical policies (medical coverage criteria) are available by calling Member Services, or on our website at www.healthpartners.com.

Indications that are covered

Items which are eligible for coverage include, but are not limited to:

  1. Professional fees directly related to dispensing, or customizing the item should be paid as part of the total eligible expense.
  2. Replacement of eligible equipment/prosthetics may be covered if the estimate for repairs is not cost effective and the item has exceeded manufacturer life expectancy. Repairs (instead of replacement) of equipment/prosthetics may be covered at the discretion of HealthPartners.
  3. Rental of medically necessary equipment, while the member's owned equipment is being repaired, is covered for 1 month. Prior authorization of the rental item will be required only for those items that currently require prior authorization.
  4. Requests for replacement DME when existing DME is not broken requires a physician statement documenting a change in covered person's physical condition, and the rationale for the replacement DME.

Indications that are not covered

Items which are not eligible for coverage include, but are not limited to:

  1. Replacement or repair of any covered items, if the items are (i) damaged or destroyed by member misuse, abuse or carelessness, (ii) lost; or (iii) stolen.
  2. Duplicate or similar items.
  3. Labor and related charges for repair estimates of any covered items which are more than the cost of replacement by a HealthPartners approved vendor.
  4. Sales tax, mailing, delivery charges, service call charges.
  5. Items which are primarily educational in nature, or for hygiene, vocation, comfort, convenience or recreation.
  6. Prostheses are not covered when requested for appearance alone. Medical necessity requires that there be a functionality issue for coverage to be approved.
  7. Communication aids or devices: equipment to create, replace or augment communication abilities including, but not limited to, hearing aids, fitting of hearing aids, speech processors, receivers, communication boards, or computer or electronic assisted communication. Please see related content at right for “Augmentative communication device” coverage policy.
  8. Household equipment which primarily has customary uses other than medical, such as, but not limited to, exercise cycles, air purifiers, central or unit air conditioners, water purifiers, non-allergenic pillows, mattresses or waterbeds.
  9. Household fixtures including, but not limited to, escalators or elevators, ramps, swimming pools and saunas.
  10. Modifications to the structure of the home including, but not limited to, its wiring, plumbing or charges for installation of equipment.
  11. Vehicle, car or van modifications including, but not limited to, hand brakes, hydraulic lifts and car carrier.
  12. Rental equipment while member's owned equipment is being repaired, beyond one month rental of medically necessary equipment.
  13. Other equipment and supplies, including but not limited to assistive devices, that we determine are not eligible for coverage.
  14. Durable medical equipment (DME) and supplies covered under a facility’s per diem are not eligible for separate reimbursement.

Definitions

An item is considered Durable Medical Equipment (DME) and may be covered if it:

  1. Can withstand repeated use, such as it could be rented or purchased and used by successive members.
  2. Is primarily and customarily used to serve a medical purpose.
  3. Generally is not useful to a person in the absence of an illness or injury.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

  • Items must be received from a contracted vendor for in-network benefits to apply.
  • Full line vendors provide a wide range of equipment and supplies, such as hospital beds, aids for ambulating and toileting, phototherapy lights, wheelchairs, custom seating devices, monitors, pumps, oxygen and etc.

Go to

Policy activity

  • 01/01/1994 - Date of origin
  • 10/23/2017 - Effective date
Review date
  • 06/2017
Revision date
  • 06/25/2018

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