Back-Up Equipment - JA DME

Backup medical equipment is defined as an identical or similar device that is used to meet the same medical need for a beneficiary but is provided for precautionary reasons to deal with an emergency when the primary piece of equipment malfunctions. Medicare does not pay separately or make an additional payment for backup equipment.

If a piece of equipment breaks down or malfunctions and it is determined that it's malfunction will result in immediate life-threatening consequences for the beneficiary, Medicare will place that item in the frequent and substantial servicing payment category. For items in this payment category, Medicare will reimburse for monthly rental payments for it if the equipment is medically necessary. The supplier must ensure there is an appropriate and acceptable contingency plan to address any emergency situations or mechanical failures of the equipment.

The expectation is that an acceptable plan involves beneficiary and his/her treating physician input and considers the severity of the his/her condition and time restraints in providing emergency support. The supplier must ensure the beneficiary's medical needs for the equipment use will be met on a continuous and ongoing basis and have a plan in place to deal with any equipment failure/interruptions that may be life-threatening. The plan may be as simple as the supplier furnishing backup equipment; however, Medicare will not pay separately and/or make any additional payment for the backup equipment. The reimbursement for the primary piece of equipment includes the cost of that piece and the frequent and substantial servicing plan the supplier must provide to ensure the beneficiary always has a working equipment. If the backup equipment is billed, it will be denied as not being reasonable and necessary.

Backup equipment must be distinguished from multiple medically necessary items that are defined as identical or similar devices, each meet a different medical need for the beneficiary. Medicare does not pay separately for backup equipment but if the beneficiary's medical needs require it to serve a different purpose, Medicare will make separate payment for a second piece of equipment.

Examples When Multiple Items May Be Covered (not all-inclusive)

• A beneficiary requires one type of ventilator (e.g., a negative pressure ventilator with a chest shell) for part of day and needs a different type of device (e.g., positive pressure respiratory assist device with a nasal mask) during rest of day
• A beneficiary who is confined to a wheelchair requires a ventilator mounted on wheelchair for use during day and needs another ventilator of same type for use while in bed. Without both pieces of equipment, beneficiary may be prone to certain medical complications, may not be able to achieve certain appropriate medical outcomes, or may not be able to use medical equipment effectively
• A beneficiary requires one type of infusion pump for a particular drug (e.g., a pump with beneficiary control features for parenteral morphine) and needs a different type of pump for another drug (e.g., continuous infusion chemotherapy)

Examples When a Second or Other Multiple Piece of Equipment May Be Considered a Backup and Are Not Covered (not all-inclusive)

• A ventilator-dependent beneficiary is confined to bed and a second ventilator of same or similar type is provided at bedside as a precaution in case of malfunction of primary ventilator

The drug epoprostenol (Flolan®) is administered using an ambulatory infusion pump and a second infusion pump is provided and billed as a precaution, if the primary pump malfunctions. Because interruption of a continuous infusion of this drug results in immediate life-threatening consequences, a unique code, HCPCS K0455, is established for an infusion pump used to administer this drug, and the code is in the frequent and substantial servicing payment category.