Article Detail - JA DME

Original Effective Date: 06/23/2011
Revision Effective Date: 11/01/2013

Supplies are a loosely defined category of items that are used with base items of DME. They are either consumed (used up) or require frequent replacement. Many DME items require supplies be used in conjunction for the base item to be functional. Some examples (not all-inclusive) are masks and tubing used with PAP devices, strips and lancets used with home glucose monitors or the drugs used with infusion pumps and nebulizers.

Payment for supplies is contingent upon the coverage of the base DME item. If the DME item is covered (meets all applicable payment requirements) then supplies used with that item are also covered. Supplies sometimes have specific coverage criteria that must be met in addition to the base item before payment can be made.

No payment may be made for supplies that are billed with dates of service (DOS) prior to the initial DOS of the base item associated with the supplies. Supplies billed with a DOS before the initial DOS of the base item will be denied as statutorily non-covered (no benefit). Suppliers are encouraged to assure that the base item is delivered on or before the delivery date of any supplies in order to avoid unnecessary denials. Sometimes multiple suppliers may be involved as in the case of nebulizers and associated drugs. This may require close coordination between all parties to avoid needless denials.

For appeals, suppliers are reminded that it is necessary to provide information from the medical record demonstrating that the coverage criteria for all items were met and that the base item was ordered, along with any supplies, prior to the DOS of the denied supplies.

Refer to the applicable LCD and Policy Article and Supplier Manual for additional information.