Durable
Medical Equipment – 90%
Benefits are
provided for durable medical equipment (DME) prescribed by a physician
including, but not limited to, crutches, wheelchairs, oxygen and oxygen-related
equipment, and standard hospital beds.
All
durable medical equipment (rental or purchase) must be preauthorized with the
Trust Office. To preauthorize
equipment, the individual or the individual’s physician must request a
Certificate of Medical Necessity form from the Trust Office. The physician must
complete the form and return it to the Trust Office. If the rental or purchase
is not preauthorized, the plan may deny the charge in part or whole. The fact
that an item may serve a useful medical purpose does not ensure that benefits
will be provided. The plan may elect to provide benefits for a less costly
alternative item.
To be covered,
the equipment must meet certain criteria established by this plan:
- The
equipment must withstand repeated use.
- The
only function of the equipment is for treatment of the medical condition or it
contributes to the improvement of function related to the condition.
- The
equipment is for the individual only.
- The
equipment is appropriate for home use. A skilled nursing facility,
rehabilitation facility or hospital is not considered an individual’s
home.
Benefits are
not
provided for:
- Equipment
received or ordered when a plan benefit is not in effect or when the individual
is not covered under this plan.
- Rental
in excess of a reasonable purchase price.
- Personal
convenience items such as, but not limited to, heating pads, enuresis (bed
wetting) training equipment, whirlpool baths, bath aids, raised toilet seats,
exercise equipment, weights, keyboard communication devices, adjustable beds,
three-wheeled scooters, orthopedic chairs, customized car seats or strollers,
personal hygiene items, blood pressure devices, breast pumps, or deluxe items
such as motorized equipment.
- Freight,
postage or delivery charges.
- Supportive
environmental services or equipment such as, but not limited to, wheelchair
ramps, support railings, air conditioners, humidifiers, or air filter
systems.
- Equipment
for which the primary purpose is preventing illness or injury; equipment
primarily designed to assist a person caring for the individual; or equipment
not useful in the absence of the individual’s condition.
- Routine
periodic servicing, such as testing, cleaning, regulating, and checking of the
individual’s equipment. Extensive maintenance based on the equipment
manufacturer’s recommendations to be performed by authorized technicians
is covered as a covered repair.
- Repair
or replacement of equipment until five years have elapsed, unless medical
necessity is proven.
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