Article Detail - JD DME

Original Effective Date: 12/03/2009
Revision Effective Date: 11/01/2013

Noridian Heathcare Solutions (Noridian) Medical Review has recently received a number of questions regarding documentation of medical necessity for vacuum erection devices (L7900). Coverage for L7900 is provided under the Prosthetic benefit which stipulates that the device must be used to replace all or part of an internal body organ. In addition to the statutory requirements, the general documentation requirements as described in Chapter 3 of the DME MAC Jurisdiction D Supplier Manual apply. For any Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) item to be covered:

The patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient's diagnosis and other pertinent information including, but not limited to, duration of the patient's condition, clinical course (worsening or improving), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. Neither a physician's order, nor a supplier-prepared statement, nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient's medical record that supports the medical necessity for the item or information on a supplier-prepared statement or physician attestation (if applicable).

Often claims for these devices do not have diagnostic information that relates to organic impotence. For patients receiving a vacuum erection device, the physician evaluation would generally include a history and physical examination focused on defining the cause of the erectile dysfunction/impotence and treatment of any co-morbid conditions that may impact sexual function. This is important to assure that specifically treatable conditions are identified before ordering a vacuum erection device. Documentation of this evaluation, conducted prior to the date of service on the claim, must be available to the DME MAC upon request. For claims that meet these documentation requirements, in addition to the ICD-9 diagnosis code for organic impotence (607.84), Noridian recommends that providers also include a secondary diagnosis to identify the cause of the impotence.

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