DMEPOS Benefit Categories
|Braces (Orthotics)||A brace is a rigid or semi-rigid device used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. Repairs, adjustments and replacement of medically necessary braces are covered.|
Durable Medical Equipment
Durable Medical Equipment (DME) is equipment which:
Supplies and accessories that are necessary for the effective use of medically necessary DME are covered. Supplies may include drugs and biologicals that must be put directly into the equipment in order to achieve the therapeutic benefit of the DME or to assure the proper functioning of the equipment.
Repairs, skilled maintenance and replacement of medically necessary DME are covered.
Effective January 1, 2011, Erythropoietin (EPO) and home dialysis equipment is no longer payable by the DME MAC.
|Home Dialysis Supplies and Equipment|| |
Effective January 1, 2011, EPO and home dialysis equipment is no longer payable by the DME MAC.
|Immunosuppressive drugs are covered if the transplant met the Medicare covered criteria in effect at the time of the transplant, the beneficiary was enrolled in Medicare Part A at the time of the transplant and the beneficiary is enrolled in Medicare Part B at the time the drugs are dispensed. Immunosuppressive drugs used for indications other than transplantation are not to be billed to the DME MAC. Supplies used in conjunction with parenterally administered immunosuppressive drugs are not covered under this benefit category.|
Oral Anticancer Drugs
Certain oral cancer drugs are covered if they have the same chemical composition and indications as the parenteral form of the drug.
Oral Antiemetics (used as full replacement for IV form)
Certain oral antiemetic drugs are covered when used as full replacement for the intravenous (IV) form of the same drug during chemotherapy treatment.
|Prosthetic Devices|| |
Prosthetic devices are items which replace all or part of an internal body organ or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ. The test of permanence is considered met if the medical record, including the judgment of the attending physician, indicates that the condition is of long and indefinite duration.
Coverage under this benefit includes, but is not limited to, artificial arms and legs, breast prostheses, eye prostheses, parenteral and enteral nutrition, ostomy supplies, urological supplies in beneficiaries with permanent urinary incontinence, and glasses or contact lenses in beneficiaries with aphakia or pseudophakia.
Supplies that are necessary for the effective use of a medically necessary prosthetic device are covered. Equipment, accessories, and supplies (including nutrients) which are used directly with an enteral or parenteral nutrition device to achieve the therapeutic benefit of the prosthesis or to assure the proper functioning of the device are covered.
Repairs, adjustments and replacement of medically necessary prosthetic devices are covered. Dental prostheses, i.e., dentures, are excluded from coverage. Claims for internal prostheses, e.g., intraocular lens, joint implants, etc. are not processed by the DME MAC.
Surgical dressings are therapeutic and protective coverings applied to surgical wounds or debrided wounds. Surgical dressings include primary and secondary dressings.
Therapeutic Shoes for Diabetics
Custom molded or extra-depth shoes and inserts for use by beneficiaries with diabetes are covered under this benefit.
While attempts have been made to include all regulatory citations, there may be inadvertent omissions. Noridian encourages users to carefully research all citations for appropriateness and applicability and not to rely on this reference list as the sole source of regulatory authority citations.
|Benefit Category||Social Security Act||Code of Federal Regulations||NCD||CMS Internet Only Manual (IOM)|
|Durable Medical Equipment (DME)|| || || |
|Prosthetics|| || || |
|Orthotics (Braces)|| || || |
|Surgical Dressings|| || ||None|
|Oral Anticancer Drugs|| ||None||None|
|Oral Antiemetics (as full IV replacement)|| ||None||None|
|Therapeutic Shoes for Diabetics|| ||None||None|
|Epoetin for Dialysis Patients|| || ||None|
|Dialysis Supplies and Equipment|| || || |
|Immuno-suppressive Drugs|| || || |
Additional Miscellaneous Citations (Exclusions from Medicare Coverage)
|Benefit Category||Social Security Act||Code of Federal Regulations||NCD||CMS Manual System|
|Personal Comfort Items|| || |
|Hearing Aids|| |
|Dental Devices|| || |
|Drugs|| || |
|Chiropractor as Ordering Physician|| || |
Last Updated Apr 13, 2017