Coverage Policy Manual
Policy #: 2009012
Category: DME
Initiated: June 2009
Last Review: August 2018
  Repair of Durable Medical Equipment (DME) and External Prosthetic Devices

Description:
Durable Medical Equipment consists of items which:
 
    • are primarily and customarily used to serve a medical purpose;
    • are not useful to a person in the absence of illness or injury;
    • are ordered or prescribed by a physician;
    • are reusable; and
    • can stand repeated use.
 
Examples of DME include but are not limited to oxygen, wheelchairs , crutches, walkers, hospital beds, traction equipment, ventilators, oxygen, monitors, lifts, and nebulizers.
 
External prosthetic devices are used to substitute for all or part of non-functioning, absent or malfunctioning body parts.  Examples of external prosthetic devices include artificial limbs, removable artificial eyes, external breast prostheses, external pacemakers and defibrillators and electronic speech aids for post-laryngectomy patients.
 
DME and prosthetic devices may occasionally need repair to restore functioning after damage or from normal wear and tear of the device.
 
Equipment used for environmental control or to enhance the environmental setting or surroundings of an individual should not be considered durable medical equipment.  Examples of these include air conditioners, air filters, humidifiers, etc.
 

Policy/
Coverage:
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
 
Repair of durable medical equipment and external prosthetic devices meets primary coverage criteria when all of the following are met:
  
    • The patient owns the equipment or external prosthesis; and
    • The required repairs are not the result of malicious damage, culpable neglect or misuse of the equipment; and
    • The expense of the repairs does not exceed the expense of purchasing a new piece of equipment or prosthesis; and
    • The equipment or external prosthesis is not currently covered by warranty.
    • The repair is necessary to make the equipment or external prosthesis usable.
 
Up to one month’s rental for a replacement device to be used while a patient-owned DME is being repaired meets primary coverage criteria.  Payment will not exceed the rental allowance for the equipment that is being repaired.
 

Rationale:
Routine maintenance such as testing, cleaning and regulating the equipment is generally the responsibility of the owner of the equipment and it is not expected that another individual would be hired to perform these services.
 
Monthly DME rental fees customarily cover the cost of maintenance and repair of the rented equipment.  Therefore, the coverage applies only for equipment that has been purchased.

CPT/HCPCS:
A4890Contracts, repair and maintenance, for hemodialysis equipment
L7510Repair of prosthetic device, repair or replace minor parts
L7520Repair prosthetic device, labor component, per 15 minutes

Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2019 American Medical Association.