Durable Medical Equipment (DME)
Your Trust group health plan provides reimbursement for the purchase or rental of durable medical equipment (DME) and supplies when we have preauthorized the expenditure; that is, you have contacted us in advance of obtaining DME and we have approved the expense.
We base our preauthorization of DME on medical necessity, medical appropriateness, and cost-effectiveness. DME is medically necessary if it is required for the safe and effective delivery of covered health care services. DME is medically appropriate if contemporary medical consensus considers it both safe and effective in the treatment of your specific medical condition. To determine whether DME is cost-effective, we will compare equipment alternatives and consider whether there are distinct medical advantages that justify greater cost or more frequent replacement. We will not preauthorize reimbursement for DME that does not provide an advantage over a suitable, less costly alternative.
What is DME?
We define DME as equipment that is:
- Primarily and customarily used to serve a medical purpose (for example, the DME is being used to treat a medical condition);
- Not useful to people who have no illness or injury; and
- Designed for long-term or repeated use.
There are literally hundreds and perhaps thousands of individual devices that are often categorized as DME. Some examples of DME that we may preauthorize include dialysis equipment, insulin infusion pumps, lymphedema pumps, and oxygen equipment.
However, not all equipment sold by a medical equipment supplier meets our definition of DME. For instance, we never cover air cleaners and purifiers, lift chairs, whirlpools, air conditioners, and exercise equipment. While equipment such as wheelchairs and hospital beds do not meet our definition of DME, we do preauthorize the use of this type of equipment when we deem it appropriate for an individual’s particular circumstances.
What we need from you
You must call us at (800) 279-4000 before you incur expenses for DME. We will need the following from you and your physician to determine if we can preauthorize reimbursement for the requested equipment:
- A prescription or letter from your physician that explains the medical rationale for the DME and includes your relevant medical history and test results.
- A treatment plan, including the recommended use of the DME along with the associated equipment codes and prices.
We will inform you of our decision regarding your preauthorization request and let you know whether the DME is covered by your plan, how much we will reimburse, and whether we will provide reimbursement for rental or purchase of the DME.
How DME is reimbursed
We have a specialty network of select organizations that will provide DME to our participants. Their contracted price is our reimbursement limit. If you choose to receive your preauthorized DME services from a provider who does not belong to the specialty network, you are financially responsible for any amount that exceeds the reimbursement limit in addition to any applicable deductible and coinsurance amounts. |
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