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HealthPartners

Coverage criteria policies

DME benefits grid

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 not applicable for items listed below

Coverage

This policy does not apply to Minnesota Health Care Program products. For MHCP products, please see Related Content box to the right for links to MHCP Provider Manual: Equipment and Supplies and MHCP Medical Supply Coverage Guide.

Items listed below are generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

See grid below

Indications that are not covered

See grid below

If available, codes are listed for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

DME item

Coverage

Criteria/limitations

Codes

Aids for visually impaired diabetics, such as: syringe magnifier (i.e. Magni-Guide), blood collection dropper (i.e. Smart Dot, Sure Shot), and non-visual insulin measurement device (i.e. Count-A-Dose).

Covered

   

Air compressor

Covered

 

E0565

Ambu bag

Covered

 

S8999

Anti-nausea wristband

Not covered - over the counter items are not a covered benefit

 

A9999

E1399

Apnea monitor

Covered - rental

 

E0618, E0619

Aqua K pad and pump

Not covered, items for comfort are not a covered benefit.

 

E0217, E0249

Bath bench

Not covered – items for comfort, convenience are not a covered benefit

 

E0245, E0247, E0248

Batteries

Limited coverage

Covered for power wheelchairs, scooters, power assist wheels, zinc air battery for use with cochlear implants and replacement batteries for wearable cardioverter defibrillators. All others are not covered including but not limited to: diabetic monitors, TENS units, hearing aids.

A4233, A4234, A4235, A4236, A4601, A4602, A4611, A4638, E1356, E2358, E2359, E2360, E2361, E2362, E2363, E2364, E2365, E2366, E2367, E2371, E2372, E2397, K0601, K0602, K0603, K0604, K0605, K0607, K0733, L7360. L7364, L7367, L8505, L8621, L8622, L8623, L8624, Q0496, Q0503, Q0506, V5266

Bed pan

Covered

 

E0275, E0276

Bedwetting/enuresis alarms

Not covered – items for comfort, convenience are not a covered benefit

Bedwetting alarms are not covered because they are considered a household item or for comfort or convenience, which is excluded in your member contract.

S8270

Bilirubin lights

Covered

 

E0202

Blood glucose test strips and their monitors/meters

Preferred blood glucose test strips and their monitors are covered. Non-preferred blood glucose test strips require prior authorization from pharmacy

The preferred Blood Glucose Testing Product List is available within the Drug Formulary.

There is a quantity limit of 200 blood glucose test strips per month for both preferred and non-preferred products. Larger amounts of test strips can be requested from HealthPartners Pharmacy Services if medically necessary.

 

Braces, sleeves, or supports made entirely of elastic

Not covered – over the counter

items are not a

covered benefit

 

A4466, A4467

Bronchial drainage board. Postural drainage board, bronchial drainage table or tilt table

Covered

 

E0606

Cane or crutches

Covered

 

E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117

Cochlear implants – replacement of external equipment

Covered

Replacement of external communication equipment is covered. External communication equipment incudes items such as mini-speech processor, microphone, headset and audio input selector, zinc air batteries, rechargeable batteries, charger.

L8614, L8615, L8616, L8617, L8618, L8619, L8621, L8622, L8623, L8624. L8627, L8628, L8629

Commode

Standard, wide or extra wide commode is covered

All others not covered – including but not limited to: shower commode, or rolling commode, commode with seat lift mechanism

 

E0163, E0165, E0168,

E0170, E0171 (not covered)

Cotton balls, alcohol wipes, rubbing alcohol, and Sharps containers

Not covered

   

Cranial remolding helmet/ band

Covered

 

S1040

Danny sling

Not covered

 

No specific code

Diabetic monitoring equipment and supplies for blood glucose and urine ketones, such as: syringes, lancets, lancet devices, control / calibrating solutions (for checking accuracy of testing equipment & test strips), and urine ketone test strips.

Covered.

   

Diabetes infusion pump supplies such as infusion sets, needles, tubing and connector, syringe reservoir, sterile insertion-site dressing (i.e. Tegaderm) and tape needed to secure.

Covered

   

DOSER for inhaled medications

Covered

 

K0730

Electrodes

Covered when required for use of item during rental period of a covered DME item

 

A4555, A4556, A4595 K0609, L8680

Electronic speech aids: artificial larynx, trachea-esophageal voice prosthesis, tracheostomy speaking-valve and voice amplifier

Covered post laryngectomy

 

L8500, L8501, L8507, L8510

Enema or bowel management kit

Enema

not covered - over the counter items are not a covered benefit

Bowel management kits - covered

 

A4649, A4458, A4459, A5102, A5200, E0350, E0352

Exercise equipment

Not covered – items for convenience, recreation are not a covered benefit

 

A9300

Foot orthotics, shoe inserts, and arch supports obtained over the counter

Not covered – over the counter

items are not a

covered benefit

 

L3040, L3050, L3060

Haberman Feeders and nipples

Covered

 

S8265

Humidifier

Humidifier -

not covered comfort, convenience items are not a covered benefit

Humidified air -

covered when part of a tracheostomy, oxygen, CPAP, BIPAP or ventilator system

 

A7046, E0550, E0555, E0560, E0561, E0562,

In-exsufflation device (also called CoughAssistTM, In-Exsufflator, CofflatorTM, cough machine) and supplies

Covered

 

E0482, A7020

Insulin pumps

Covered

 

E0784

Intermittent positive pressure breathing (IPPB)

Covered

 

E0500

Iontophoresis machine

Not covered

Not covered for home use as they are a comfort, convenience or recreational items

E1399

IV therapy and pump supplies

Covered

 

A4213, A4220, A4221, A4222, A4223, A4300, A4301, A4305, A4306, E0776, E0781, E0791, K0105, S1015,

K-Y jelly

Not covered - over the counter

 

A9999 or E1399

Medical alert systems

Not covered

 

A9280

mySentry remote glucose monitor

Not covered

Convenience item

E1399

Nebulizer

Covered

 

A7003, A7004, A7005, A7006, A7007, A7008, A7017, E0570, E0572, E0574, E0575, E0580, E0585

Needles/syringes

Covered

 

A4206, A4207, A4208, A4209, A4212, A4213, A4215, A4232, A4322, A4657, C1715, C1830, C2618, K0552, S8490

Oscillatory positive expiratory pressure device, nonelectric, any type, each

Covered

 

E0484

Ostomy supplies

Covered

Colostomy / Ileostomy / Nephrostomy / Ureterostomy - Covered supplies include items such as belt, pouch, bags, wafer, face plate, insert, barrier, filter, gasket, plug irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, pouch deodorant, gauze and skin barrier preps.

A4357, A4361, A4364, A4366A4369, A4371, A4373, A4375, , A4378, A4384, A4385, A4387, A4390, A4394, , A4396, A4398, A4400, A4402, A4404, A4427, A4435, A4450, A4452, A4455, A4456, A4397, A5051, A5052, A5057, A5061, A5063,A5081, A5083 A5093, A5102, A5120, A5122, A5126, A5131

Overbed table

Not covered – convenience items are not a covered benefit (Unless enrolled in hospice)

 

E0274

Oximeter

Covered

 

E0445

Parrafin bath-portable

Not covered – items for comfort, convenience are not a covered benefit

 

E0235

Patient lifts (Hoyer, etc)

Coverage varies

E0625,E0630, E0637 (hydraulic or mechanical lift) are covered

E0635,E0636, E0639 (electric lift) are not covered

E0625,E0630, E0637, E0635,E0636, E0639

Peak flow meter

Covered

 

A4614, S8096, S8097

Percussor

Covered

 

E0480

Pleural effusion drainage systems

Covered

 

A7048

Prothrombin time monitors

Covered

 

G0248,G0249,G0250

Respiratory assist device

Covered

Excludes vests (E0483)

E0470, E0471, E0472

Scales

Not covered – items for comfort, convenience are not a covered benefit

Contract exclusion, household equipment

A9999 or E1399

Seating support cushion

(for wheelchair seating support, refer to Wheelchairs – Mobility Assist Equipment (MAE) policy)

Not covered, items for comfort, convenience are not a covered benefit

 

No specific code

Sitz baths

Not covered, items for comfort, convenience are not a covered benefit

 

E0160, E0161, E0162

Spacers for use with inhalers

Covered

Types of spacers include Aerochamber™, Breathancer™, Inhal-Aid™, Inspirease™, Spinhaler-Turbo™ and OptiChamber®.

A4627, S8100, S8101

Splints

Covered

   

Standing frame/stander

Covered

 

E0637, E0638, E0641, E0642

Suction machine and catheters

Covered

Coverage is limited to no more than 3 months stock of catheters at a time.

A7002, A4605, A4624, A4628, E0600, E2000

Therapeutic light box; table top or desk top lightboxes

Covered

Floor stands, carrying case, and optional desk stands are not covered as they are a comfort, convenience or recreational items

E0203,A9999

Tracheostomy supplies

Covered

Covered items include trach tube, ties (also referred to as twill tape), holders, cannula, tracheostomy care kit, tube brush, pipe cleaners, cotton tip applicators, 4x4 sponge/gauze, saline, sterile water. No more than a 3 month stock is covered at a time. Tracheostomy speaking valve, also called a stint or tracheal esophageal speaking valve, is covered.

A4481, A4605, A4623, A4624, A4625, A4626, A4629, A7501, A7502, A7503, A7504, A7505, A7506, A7507, A7508, A7509, A7520, A7521, A7522, A7523, A7524, A7525, A7526, A7527, L8501, S8189

Traction equipment

Covered except for spinal unloading devices and spinal decompression therapy

Basic standard traction units are covered for cervical and pelvic (low back) traction.

E0830, E0840, E0849

Transfer belt

Covered

 

E0705

Transfer board

Covered

A basic transfer board is covered

E0705

Truss

Covered

 

L8300, L8310, L8320, L8330

Urinal

Covered

 

E0325, E0326

Urinary supplies

Covered

 

A4321, A4327, A4328, A4331, A4333, A4334, A4351, A4352, A4353, A4356, A4357, A4358, A4360, A5105, A5112

Vaginal cones or dilators

Covered

 

A9999 or E1399

Ventilator and supplies

Covered

A ventilator is a rental item only. Supplies (usually purchase only) required to maintain the ventilator are covered.

A4483, A4611, A4612, E0465, E0466

Vitrectomy table

Covered

The face support equipment and necessary chair or table support attachments are covered. Rental only

E1399

Wearable defibrillator and replacement garments and electrodes

Covered

 

K0606, K0608 and K0609

Wedges, pillows, cushions

Not covered – items for comfort, convenience are not a covered benefit

   

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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

For in-network benefits to apply, item must be received from a contracted vendor or provider.

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Policy activity

  • 02/22/2017 - Date of origin
  • 10/01/2018 - Effective date
Review date
  • 01/2018
Revision date
  • 08/24/2018

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