Durable Medical Equipment—90%
Services and Supplies Must Be Preauthorized With the
Trust Office
Benefits are provided for durable medical
equipment (DME) prescribed by a physician
for use in the patient's home including, but
not limited to, crutches, wheelchairs, oxygen
and oxygen-related equipment, and standard
hospital beds. Extensive maintenance based
on the equipment manufacturer's recommendations
to be performed by authorized
technicians is covered.
To preauthorize equipment, you or your physician
must supply documentation of medical
necessity or you may request a Certificate of
Medical Necessity form from the Trust Office
for your physician to complete. 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 also elect to provide
benefits for a less costly alternative item.
To be covered, the equipment must meet certain
criteria established by this plan:
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 patient only.
- The equipment is appropriate for home use.
A skilled nursing facility, rehabilitation
facility or hospital is not considered the
patient's home.
Benefits are not provided for:
- Equipment received or ordered when a
plan benefit is not in effect or when the
patient 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, muscle stimulators,
weights, keyboard communication
devices, adjustable beds, three-wheeled
scooters, orthopedic chairs, customized
car seats or strollers, feeding chairs,
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 patient; or equipment not
useful in the absence of the patient's condition.
- Routine periodic servicing, such as testing,
cleaning, regulating, and checking of
the patient's equipment.
- Repair or replacement of equipment until
five years have elapsed, unless medical
necessity is proven.
- Batteries.
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