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HealthPartners

Coverage criteria policies

Equipment in skilled nursing / long term care facility

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

  • This policy applies to members who reside in a Skilled Nursing Facility (SNF), Nursing Facility (NF), or Long Term Care Facility (LTC).
  • For members who reside in a Skilled Nursing Facility (SNF), Nursing Facility (NF) or Long Term Care Facility (LTC):
    • Routine DME (see definition below) which would normally require prior authorization is reviewed under the Equipment in a SNF/LTC coverage policy.
    • Ancillary DME (see definition below) is reviewed under the item’s individual coverage policy.
  • For members whose room & board stay is covered by Medicare or HealthPartners, most DME is included in the facility’s per diem.

Coverage

Generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

Ancillary DME is subject to review under the item’s unique coverage policy.

Ancillary DME may be eligible for rental or purchase. Including but not limited to: life support ventilators, CPAP, BIPAP, oxygen system, seating support systems, TENS, NMES, electrodes, slings, negative pressure wound therapy pump (Wound VAC) (E2402), powered pressure reducing mattress (low air loss or alternating pressure) and other pressure reducing support surfaces (mattress for bed), etc.

  1. Prosthetics and orthotics coverage – refer to the Prosthetic Limb & the Orthotics/Braces policies
  2. A manual Tilt-in-Space wheelchair is eligible for coverage when:
    1. Member must have multiple medical problems that cannot be accommodated with other positioning adaptations and other alternatives must have been exhausted.
  3. Custom adaptations to a member owned manual wheelchair may be covered on a case by case review. Decision will be based on medical appropriateness.

Indications that are not covered

  1. Routine DME and supplies:
    1. Examples of routine DME include but are not limited to: wheelchairs, walkers, hospital beds, canes, commodes, traction equipment, formula, suction machines, patient lifts, weight scales, etc.
    2. Examples of routine supplies include but are not limited to ostomy supplies, enteral feeding supplies, wheelchair cushions, urinary catheters & supplies, wound care / dressing supplies (A6010-A6457) etc.
  2. Power mobility devices are not covered in a SNF/NF/LTC because the facility provides 24 hour nurse caregivers that are able to mobilize a member in a manual wheelchair.

Definitions

Assisted Living Facilities and Board and Care Facilities are not considered SNF's.

Skilled Nursing Facility (SNF) means a facility that is certified by Medicare to provide inpatient skilled nursing care, rehabilitation services or other related health services. Such services can only be performed by, or under the supervision of, licensed nursing personnel.

Nursing Facility (NF) means a long term care facility (LTC) certified by the Minnesota Department of Health for services provided and reimbursed under Medicaid. Also known as Nursing Home or long term care.

Routine DME/supplies are expected to be available and supplied by the SNF/NF/LTC. Examples of routine DME include but are not limited to: wheelchairs, walkers, hospital beds, canes, commodes, traction equipment, formula, suction machines, patient lifts, weight scales, etc. Examples of routine supplies include but are not limited to ostomy supplies, enteral feeding supplies, wheelchair cushions, urinary catheters & supplies, wound care / dressing supplies (A6010-A6457) etc.

Ancillary DME/Supplies is tailored exclusively to an individual’s specific medical needs and is ordered under the direction of a physician. These items are more complex medical equipment and may be considered for coverage under the DME benefit. Items include, but are not limited to: life support ventilators, CPAP, BIPAP, oxygen system, seating support systems, TENS, NMES, electrodes, slings, negative pressure wound therapy pump (Wound VAC) (E2402), etc.

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.

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Policy activity

  • 03/01/1998 - Date of origin
  • 02/01/2017 - Effective date
Review date
  • 02/2017

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