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DMEPOS Benefit Categories

Medicare Part B covered services processed by the DME MAC fall into the following benefit categories specified in Section 1861 (s) of the Social Security Act:

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Category Brief Description
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 (DME) Durable Medical Equipment (DME) is equipment which:
  • Can withstand repeated use,
  • Is primarily and customarily used to serve a medical purpose,
  • Generally is not useful to a person in the absence of an illness or injury, and
  • Is appropriate for use in the home.

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.

Erythropoietin 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.
Immuno-suppressive Drugs 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 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.

 

Citations for DMEPOS Benefit Categories

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)
  • Section 1834(a)[42 USC Section 1395m(a)]
  • Section 1834(j)(5)(A)[42USC Section 1395m(j)(5)(A)]
  • Section 1861(n)[42 USC Section 1395x(n)]
  • Section 1861(m)(5)[42 USC Section 1395x(m)(5)]
  • Section 1861(s)(6)[42 USC Section 1395x(s)(6)]
  • 42 CFR Sections 410.38, 414.200-414.232 (1998)
  • 20.8.2
  • 40.2
  • 50.1
  • 230.8
  • 240.2
  • 240.4
  • 240.5
  • 270.2
  • 280.1
  • 280.13
  • 280.14
  • 280.3
  • 280.4
  • 280.5
  • 280.6
  • 280.7
  • 280.8
  • 280.9
Prosthetics
  • Section 1832(a)(2)(I)[42 USC Section 1395k(a)(2)(I)]
  • Section 1833(a)[42 USC Section 1395l(a)]
  • Section 1834 (h) and (j)(5)(C)[42 USC Section 1395m(a) and (j)(5)(C)]
  • Section 1861(s)(8) and (9)[42 USC Section 1395x(s)(8) and (9)]
  • Section 1862(a)(7)[42 USC Section 1395y(a)(7)]
  • 42 CFR Sections 410.36, 414.1, 414.202, 414.210, 421.210, 424.57 (1998)
  • 20.8
  • 20.9
  • 50.2
  • 50.3
  • 80.4
  • 80.5
  • 160.7
  • 180.2
  • 230.10
  • 230.15
  • 230.16
  • 230.17
Orthotics (Braces)
  • Section 1832(a)(2)(I)[42 USC Section 1395k(a)(2)(I)]
  • Section 1833(a)[42 USC Section 1395l(a)]
  • Section 1834 (h) and (j)(5)(C)[42 USC Section 1395m(a) and (j)(5)(C)]
  • Section 1861(s)(9)[42 USC Section 1395x(s)(9)]
  • Section 1862(a)(8)and (13)[42 USC Section 1395y(a)(8) and (13)]
  • 42 CFR Sections 410.36, 411.15, 414.1, 414.202, 414.210, 421.210, 424.57 (1998)
  • 280.1
  • 280.10
  • 280.11
  • 280.12
Surgical Dressings
  • Section 1833(a)(1)(P)[42 USC Section 1395l(a)(1)(P)]
  • Section 1834(i) and (j)(D)[42 USC Section 1395m(i) and (j)(5)]
  • Section 1861(s)(5)[42 USC Section 1395x(s)(5)]
  • 42 CFR Sections 410.36, 414.220, 414.210 (1998)
None
Oral Anticancer Drugs
  • Section 1834(j)(5)(F)(iv)[42 USC Section 1395m(j)(5)(F)(iv)]
  • Section 1861(s)(2)(Q) [42 USC Section 1395x(s)(2)(Q)]
None None
Oral Antiemetics (as full IV replacement)
  • Section 1861(s)(2)(T)
None None
Therapeutic Shoes for Diabetics
  • Section 1833(o)[42 USC Section 1395l(o)]Section 1834(j)(5)(F)[42 USC Section 1395m(j)(5)(F)]
  • Section 1842(s)(2)(c)[42 USC Section 1395u(s)(2)(c)]
  • Section 1861(s)(12)[42 USC Section 1395x(s)(12)]
None None
Epoetin for Dialysis Patients
  • Section 1834(j)(5)(F)(v)[42 USC Section 1395m(j)(5)(F)(v)]
  • Section 1861(s)(2)(O)[42 USC Section 1395x(s)(2)(O)]
  • 42 CFR Sections 410.10, 410.50, 410.52, 413.174, 414.300, 414.335 (1998)
None
Dialysis Supplies and Equipment
  • Section 1834(j)(5)(F)(i)[42 USC Section 1395m(j)(5)(F)(i)]
  • Section 1842(s)(2)(B)[42 USC Section 1395u(s)(2)(B)]
  • Section 1861(s)(2)(F)[42 USC Section 1395x(s)(2)(F)]
  • Section 1881[42USC Section 1395rr]
  • 42 CFR Sections 405.2140, 405.2163, 410.10, 410.50, 410.52, 413.174, 413.198, 414.300, 414.330, 421.210 (1998)
  • 230.7
  • 230.13
  • 230.14
Immuno-suppressive Drugs
  • Section 1834(j)(5)(F)(ii)[42 USC Section 1395m(j)(5)(F)(ii)]
  • Section 1861(s)(2)(J)[42 USC Section 1395x(s)(2)(J)]
  • 42 CFR Sections 410.10, 410.30, 421.210 (1998)
  • 260.1
  • 260.7

 

Additional Miscellaneous Citations (Exclusions from Medicare Coverage)

Benefit Category Social Security Act Code of Federal Regulations NCD CMS Manual System
Personal Comfort Items
  • Section 1862(a)(6)[42 USC Section 1395y(a)(6)]
 
  • 280.1
Hearing Aids
  • Section 1862(a)(7)[42 USC Section 1395y(a)(7)]
   
Immunizations
  • Section 1862(a)(7)[42 USC Section 1395y(a)(7)]
   
Dental Devices
  • Section 1862(a)(7)[42 USC Section 1395y(a)(7)]
 
  • 260.6
Drugs
  • Section 1861(t)[42 USC Section 1395x(t)]
  • Section 1862(c)(1)[42 USC Section 1395y(c)(1)]
  • 42 CFR Section 410.29
 
Chiropractor as Ordering Physician
  • Section 1861(r)(5 )
  • 42 CFR Section 410.21(b)
   

 

Last Updated Jun 13, 2017