Humana Commercial Clinical Policy

Humana Durable Medical Equipment Form

Effective Date

10/03/2023

Last Reviewed

NA

Original Document

  Reference



Coverage Determination

Please consult individual certificate regarding Plan coverage for durable medical equipment.

It is the Plan’s option to determine if the DME item shall be rented or purchased. If the cost of renting the item is more than the cost to buy it, only the cost of the purchase is considered to be a covered expense. In either case (rent or purchase), total covered expenses shall not exceed the purchase price. In the event the Plan determines to purchase the DME, any amount paid as rent for such equipment will be credited toward the purchase price.

Humana members may be eligible under the Plan for durable medical equipment (DME), for the following indications:

  • Must meet the definition for DME:
    • Can withstand repeated use (could normally be rented and used by successive individuals); AND
    • Generally is not useful to an individual in the absence of illness or injury; AND
    • Is appropriate for use in an individual’s home or may be necessary for use at other locations or in the community to allow basic activities of daily living (ADLs); AND
    • Is primarily and customarily used to serve a medical purpose rather than being primarily for comfort or convenience; AND
  • Must be prescribed by a health care practitioner; AND
  • Must be related to and meet the basic functional needs of the individual’s physical disorder/condition; AND
  • Not furnished by a hospital or skilled nursing facility; AND
  • Provided in the most cost effective manner required for the individual’s condition, including, at the Plan’s discretion, rental or purchase

Repair/Replacement

Please consult the member's individual certificate regarding Plan coverage for repairs/maintenance and replacement of DME.

Repairs and maintenance of purchased DME equipment may be a covered expense if:

  1. The manufacturer’s warranty has expired; AND
  2. The repair or maintenance is not the result of misuse or abuse; AND
  3. The repair cost is less than replacement cost

Replacement of purchased DME equipment may be a covered expense if:

  1. Replacement is required due to a change in an individual’s condition that makes the current device/equipment non-functional; OR
  2. Manufacturer’s warranty has expired; AND
  3. Reasonable useful lifetime wear and tear is generally 5 years; therefore replacement is generally not required more frequently than every 5 years; AND
  4. Replacement cost is less than the repair cost; AND
  5. Replacement is not due to lost or stolen device/equipment, misuse or abuse of the equipment; AND
  6. Replacement is required due to current device/equipment being nonfunctional (malfunctioning and cannot be repaired); AND
  7. Requested device/equipment is being prescribed according to its US Food & Drug Administration (FDA) approved indications
Add-ons/upgrades:

Please consult the member’s individual certificate regarding Plan coverage for add-ons or upgrades.

When add-ons or upgrades are beyond what is necessary to meet the individual’s basic functional medical needs, they are generally not considered medically necessary.

Duplicative equipment:

Please consult the member’s individual certificate regarding Plan coverage for duplicative equipment or similar equipment, which includes, but may not be limited to, equipment with the same function for use in another location (eg, school, second residence, travel, work) as it may be excluded by certificate. In the absence of a certificate exclusion, this is considered not medically necessary as defined in the member’s individual certificate.

Note:

The criteria for seat lifts are consistent with the Medicare National Coverage Policy and therefore apply to Medicare members.

Note:

The criteria for durable medical equipment, air-fluidized bed, home blood glucose monitors, home prothrombin time monitors, hospital beds, infusion pumps and mobility assistive devices are not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

All DME in the chart below are listed according to the following categories:

EQUIPMENT/DEVICE
COMMENTS/COVERAGE INSTRUCTIONS
AMBULATORY AIDS
  • Canes (E0100, E0105) – Individual’s condition must impair ambulation
  • Crutches (eg, standard [axillary/underarm], forearm) (E0110 — E0114, E0116) – Individual’s condition must impair ambulation
  • Crutch, sit & stand walking assistant type crutch (E1399) – NOT COVERED - not medically necessary
  • Crutch, underarm, articulating, spring assisted (E0117) – NOT COVERED - not medically necessary
  • Floor/Mobile Stander (eg, Rifton [Supine, Prone or Mobile] or Squiggles) – See Mobility Assistive Devices (Wheelchairs) Medical Coverage Policy

Durable Medical Equipment (DME) Effective Date: 10/03/2023 Revision Date: 10/03/2023 Review Date: 02/02/2023 Policy Number: HUM-0429-041 Page: 5 of 45

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Gait Trainer (eg, Buddy Roamer Pediatric Gait Trainer, Leckey MyWay, Rifton Pacer) (E0140, E8000 – E8002) - Covered ONLY for children with cerebral palsy or other severe neuromuscular conditions
  • Kneeling Walker/Knee Walker/Rolling Knee Walker (eg, Roll-A-Bout Walker, Turning Leg Caddy)/Kneeling Crutch (eg, iWALKFree) (E0118) - NOT COVERED
  • Pediatric Posterior Walker (eg, Flux Walker, Kaye 4-Wheeled Posterior Walker, Nimbo Walker) (E1399) - Child must meet criteria for a standard pediatric walker AND require the additional stability offered by a posterior walker due to a neurological condition (eg, cerebral palsy) OR is unable to use a standard walker but can maneuver a posterior walker
  • Pediatric Walker with Seat (eg, Kaye PostureRest Walkers with seat, Nimbo with fold-down seat or soft seat harness) (E1399) - Child must meet criteria for a standard pediatric walker AND requires a seating option in order to perform ADLs, due to decreased endurance or inability to stand for prolonged period of time
  • UpSee Mobility Device (E1399) - NOT COVERED - over-the-counter (OTC)*
  • Walker — Heavy-duty (E0148, E0149) - Individual must meet criteria for a standard walker AND weight exceeds 300 pounds
  • Walker — Heavy-duty, Multiple braking System, Variable Wheel Resistance (E0147) - Individual must meet criteria for a standard walker AND have severe neurological disorder or restricted use of one hand and therefore unable to use a standard device
  • Walker — Standard (E0130, E0135, E0141, E0143) - Individual’s condition must impair ambulation
  • Walker — Walker, Enclosed, 4 sided framed, rigid or folding, wheeled with posterior seat (E0144) - NOT COVERED - not medically necessary (convenience item)
BATHTUB EQUIPMENT
  • Bathing Systems (eg, Otter Bathing System, Rifton Wave Bathing System, Ultima Bath Chair) (E1399) - NOT COVERED — OTC*
  • Bathtub Lift (eg, Aqualift bath system, Marlin lift) (E0625) - Generally EXCLUDED by certificate** (not primarily medical in nature); refer to the member’s individual certificate language

Durable Medical Equipment (DME) Effective Date: 10/03/2023
Revision Date: 10/03/2023
Review Date: 02/02/2023
Policy Number: HUM-0429-041
Page: 6 of 45

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

BATHTUB EQUIPMENT
  • Bathtub Seat/Bench (E0240, E0245, E0247, E0248) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
  • Bed Bath (E1399) - NOT COVERED — OTC*
  • Grab Bars (E0241, E0242, E0246, E0700) - NOT COVERED — OTC*
  • Rolling Shower Frame/Chair (eg, Columbia Medical Ultima Rolling Shower Chair, R82 Manatee Rolling Shower Frame, Rifton HTS) (E0240) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
  • Sauna Bath (E1399) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

Durable Medical Equipment (DME) Effective Date: 10/03/2023
Revision Date: 10/03/2023
Review Date: 02/02/2023
Policy Number: HUM-0429-041
Page: 7 of 45

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

HOSPITAL BEDS
  • Hospital Bed – Extra Heavy Duty, Extra Wide (E0302, E0304) - Individual must meet criteria for a manual hospital bed AND weight exceeds 600 pounds
  • Hospital Bed – Fully Electric (E0265, E0266, E0296, E0297) - NOT COVERED — not medically necessary
  • Hospital Bed – Heavy Duty, Extra Wide (E0301, E0303) - Individual must meet criteria for a manual hospital bed AND weight is greater than 350 pounds, but less than 600 pounds
  • Hospital Bed – Manual (E0250, E0251, E0255, E0256, E0290 – E0293) - Individual must be bed-confined AND one of the following: e Condition that requires position changes an ordinary bed cannot accommodate; OR e Condition requires frequent position changes
  • Hospital Bed/Crib — Pediatric (E0300, E0328, E0329) - Child must be bed-confined AND one of the following: e Condition that requires position changes an ordinary bed cannot accommodate; OR e Condition requires frequent position changes
  • Hospital Bed — Semi-Electric (E0260, E0261, E0294, E0295) - Individual must meet criteria for a manual hospital bed AND all of the following: e Delay in position change cannot be tolerated; AND e Must be able to operate bed controls (except individuals
OTHER EQUIPMENT
  • Lounge Bed/Non-Hospital Bed (e.g., Craftmatic Adjustable Bed, Electropedic Adjustable Bed, Sealy Posturepedic Bed, Simmons Beautyrest Adjustable Bed, Select Comfort/Sleep Number) - NOT COVERED — OTC*
  • Overbed Table (E0274, E0315) - home use NOT COVERED — OTC*
  • Safety Enclosure Frame/Canopy (E0316) - Covered for use with hospital bed when criteria for the hospital bed are met AND the individual is at risk for falls or if climbing out of bed is a concern
  • Safety Sleep Beds (e.g., Abrams Safety Sleeper, Courtney Bed, Cubby Plus, Safe Haven, Sleep Safe Bed) (E1399) - NOT COVERED — OTC*

Durable Medical Equipment (DME) Effective Date: 10/03/2023
Revision Date: 10/03/2023
Review Date: 02/02/2023
Policy Number: HUM-0429-041
Page: 8 of 45

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Snoo Smart Sleep Bassinet (E1399) - NOT COVERED - OTC*
  • Springbase Bed (E0462) - NOT COVERED - institutional equipment; inappropriate for home use
  • Stryker Frame Bed (E0270) - NOT COVERED - institutional equipment; inappropriate for home use
  • Trapeze Bar (E0910 — E0912, E0940) - Individual must meet criteria for a manual or semi-electric hospital bed AND unable to sit up, change positions or get in/out of bed without its use
BREAST-RELATED SUPPLIES
  • Bra, Post-Mastectomy - See Prosthetics Medical Coverage Policy
  • Breast Prosthesis - See Prosthetics Medical Coverage Policy
  • Breast Pump — Manual, Electric (AC or DC) (E0602, E0603) - Covered for initiation or continuation of breastfeeding; this would include double electric breast pumps
  • Breast Pump — Hospital Grade (E0604) - Covered as rental only, for initiation or continuation of breastfeeding, AND any of the following:
    • Newborn/infant has a medical (eg, cardiac, respiratory, genetic) or congenital (eg, cleft palate, cleft lip) condition that interferes with effective breastfeeding; OR
    • Newborn/infant remains in the hospital after the mother’s discharge; OR
    • The mother has a medical condition or anatomic anomaly that prevents effective breastfeeding
  • Breast Pump — Wireless (eg, Willow Wearable Breast Pump) (E1399) - NOT COVERED - not medically necessary (convenience item)

Durable Medical Equipment (DME) Effective Date: 10/03/2023
Revision Date: 10/03/2023
Review Date: 02/02/2023
Policy Number: HUM-0429-041
Page: 9 of 45

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Breast Pump Supplies:
  • Supplies are limited to the following, during the time that the replacement
  • A4281 - 2 replacement items every 12 months
  • A4282 — Adapter for breast pump, A4282 - 1 replacement item per birth
  • A4283 — 2 replacement items every 12 months
  • A4283 — Cap for breast pump bottle, A4284 - 2 replacement items every 12 months
  • A4284 - Breast shield & splash protector for use with breast pump, replacement
  • A4285 — 2 replacement items every 12 months
  • A4285 — Polycarbonate bottle for use with breast pump, replacement
  • A4286 — Locking ring for breast pump,
  • K1005 — Disposable collection bag and storage bag for breast milk, any size, any type

Lymphedema Garment: See Lymphedema - Diagnosis and Treatment Medical Coverage Policy

COMMUNICATIONS SYSTEMS
  • Braille Teaching Texts (E1399) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
  • Communication Aid - See Speech Generating Devices, Voice Prostheses Medical Coverage Policy
  • Communicator - See Speech Generating Devices, Voice Prostheses Medical Coverage Policy
  • Electric/Computer Communication Devices and Software Programs - See Speech Generating Devices, Voice Prostheses Medical Coverage Policy
  • Picture Communication Symbols/Picture Boards (E1902) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
  • Telephone Alert Systems (V5269) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
  • Touch Talker (E1399) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
  • Vocaid (E1399) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

Durable Medical Equipment (DME) Effective Date: 10/03/2023
Revision Date: 10/03/2023
Review Date: 02/02/2023
Policy Number: HUM-0429-041
Page: 10 of 45

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

CUSHIONS, PADS AND MATTRESSES
  • Abduction Pillow (E1399) - Covered for a child with hip disorders
  • Air Mattress or Alternating Air Pressure Pad/Mattress (E0181, E0186, E0197) - Individual must have, or be highly susceptible to, decubitus ulcers
  • Aquamatic K-Pad - See Cold Therapy Devices/Heating Devices/Combined Heat and Cold Therapy Devices Medical Coverage Policy
  • Dolphin Immersion Mattress (Dolphin Fluid Immersion Simulation [FIS] System) (E1399) - NOT COVERED - institutional equipment; inappropriate for home use
  • Dreama 24 hr Positioning System (may also be referred to as Dreama Posture Mattress) (E1399) - NOT COVERED -- experimental/investigational
  • Elbow Protector (E0191) - Individual must have, or be highly susceptible to, decubitus ulcers
  • Gel Floatation Pad/Mattress (E0185, E0196) - Individual must have, or be highly susceptible to, decubitus ulcers
  • Heat & Massage Foam Cushion Pad (E1399) - NOT COVERED — OTC*
  • Heating Pad - See Cold Therapy Devices/Heating Devices/Combined Heat and Cold Therapy Devices Medical Coverage Policy
  • Heel Protector (eg, Z-Flex Fluidized heel boots) (E0191) - Individual must have, or be highly susceptible to, decubitus ulcers
  • Hip Positioning Kit (E0190) - NOT COVERED — OTC*
  • Lamb’s Wool Pad (E0188, E0189) - Individual must have, or be highly susceptible to, decubitus ulcers
  • Mattress (regular, for hospital bed) (E0271, E0272) - Covered for an individual who qualifies for manual or semi-electric hospital bed at home
  • Mattress for safety sleep beds (which are noncovered beds) (E1399) - NOT COVERED — OTC*
  • Mattress Overlay (pressure relief overlay, including RoHo Dry Floatation Mattress, RoHo Prodigy Mattress Overlay System) (E0371, E0372) - Individual must have, or be highly susceptible to, decubitus ulcers
  • Nonpowered Advanced Pressure Reducing Mattress (E0373) - Individual must have, or be highly susceptible to, decubitus ulcers

Durable Medical Equipment (DME) Effective Date: 10/03/2023
Revision Date: 10/03/2023
Review Date: 02/02/2023
Policy Number: HUM-0429-041
Page: 11 of 45

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Powered pressure-reducing air mattress:
  • Low Air Loss Mattress System) (E0277)
  • Individual must have, or be highly susceptible to, decubitus ulcers
Powered pressure-reducing underlay/pad:
  • Alternating, with pump, includes heavy duty (eg, Toto Lateral Turning System) (E0183)
  • NOT COVERED - experimental/investigational
Steam (Hydrocollator) Pack:
  • (E0225)
  • NOT COVERED - OTC*
Water & Pressure Pads & Mattresses:
  • (E0184, E0187, E0198, E0199)
  • Individual must have, or be highly susceptible to, decubitus ulcers
DIABETIC EQUIPMENT
Blood Glucose Monitoring Devices:

May be covered under member's Pharmacy benefits; refer to the member's individual certificate language

Continuous Glucose Monitoring Devices:

See Continuous Glucose Monitoring Systems and Insulin Pumps Medical Coverage Policy

Insulin Infusion Pump:

See Continuous Glucose Monitoring Systems and Insulin Pumps Medical Coverage Policy

Lancet, Laser:
  • (E0620)
  • NOT COVERED - not medically necessary (convenience item)
Pen Pump Syringe:

May be covered under member's Pharmacy benefits; refer to the member's individual certificate language

ELECTRICAL/NEUROMUSCULAR STIMULATORS
Anodyne Therapy System (Monochromatic Infrared Energy):

See Code Compendium (Wound Care) Medical Coverage Policy

Bone Growth Stimulators:

See Bone Growth Stimulators Medical Coverage Policy

Electrical Stimulation for Wounds:

See Electrical Stimulation and Electromagnetic Therapy for the Treatment of Wounds Medical Coverage Policy

Electrical Stimulators:

See Electrical Stimulators for Pain and Nausea/Vomiting Medical Coverage Policy

Functional Electrical Stimulators:

See Electrical Stimulators — Diaphragmatic/Phrenic Nerve Functional and Neuromuscular Medical Coverage Policy

Neuromuscular Stimulators:

See Electrical Stimulators — Diaphragmatic/Phrenic Nerve, Functional and Neuromuscular Medical Coverage Policy

Durable Medical Equipment (DME) Effective Date: 10/03/2023
Revision Date: 10/03/2023
Review Date: 02/02/2023
Policy Number: HUM-0429-041
Page: 12 of 45

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Pelvic Floor Stimulator for Urinary Incontinence

See Urinary Bladder Dysfunction Medical Coverage Policy

TENS Unit

See Electrical Stimulators for Pain and Nausea/Vomiting Medical Coverage Policy

Transcranial Electrical Stimulator

See Transcranial Magnetic Stimulation and Cranial Electrical Stimulation Medical Coverage Policy

ENVIRONMENTAL CONTROL ITEMS

Air Cleaner, Air Purifier (E1399)

Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

Air Conditioner (E1399)

Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

Dehumidifier (E1399)

Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

Electric Air Cleaner/HEPA Filter (E1399)

Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

Electrostatic Machine (E1399)

Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

Environmental Control Equipment (E1399)

Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

Heater, Portable (E1399)

Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

Humidifier (central or room) (E1399)

Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

Micronaire Air Cleaner (E1399)

Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

EXERCISE EQUIPMENT

Continuous Passive Motion (CPM) Device

See Continuous Passive Motion (CPM) and Mechanical Stretching Devices Medical Coverage Policy

Exercise Equipment (A9300)

Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

Exercycle/exercise bike (including for cardiac use) (A9300)

Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

Durable Medical Equipment (DME) Effective Date: 10/03/2023
Revision Date: 10/03/2023
Review Date: 02/02/2023
Policy Number: HUM-0429-041
Page: 13 of 45

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

EXERCISE EQUIPMENT
  • Inversion Table (E0941) - NOT COVERED — OTC*
  • Parallel Bars (E1399) - NOT COVERED - institutional equipment; inappropriate for home use
  • Pedometer (A9300) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
  • ROMTech Adaptive Rehab Portable Connect (E1399) with Knee AccuAngle (A9900) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
  • Training Balls (A9300) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
  • Treadmill (A9300) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
EYEWEAR

Covered for the initial pair of eyeglasses or contact lenses needed following cataract surgery or an accident; for accidents, they will only be covered if the eyeglasses or contact lenses were not needed prior to the accident. Refer to the member’s individual certificate of coverage.

LIFTS
  • Bathtub Lift (eg, Aqualift Bath System, Marlin Lift) (E0625) - Generally EXCLUDED by certificate** (not primarily medical in nature); refer to the member’s individual certificate language
  • Bed Lifter/Riser (bed elevator) (E1399) - NOT COVERED — OTC*
  • Electric Powered Recliner and Elevating Seat (E1399) - NOT COVERED — OTC*
  • Elevator (E1399) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
  • Patient Lift, Bathroom or Toilet (E0625) - Generally EXCLUDED by certificate** (not primarily medical in nature); refer to the member’s individual certificate language
  • Patient Lift (eg, electric, Hoyer, hydraulic) (E0621, E0630, E0635) - Individual must be unable to transfer out of bed without a lift AND periodic movement from bed will significantly improve, arrest or retard deterioration
  • Patient Lift (may or may not require home modification [eg, ceiling tracks/lifts]) (E0639, E0640) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

Durable Medical Equipment (DME) Effective Date: 10/03/2023
Revision Date: 10/03/2023
Review Date: 02/02/2023
Policy Number: HUM-0429-041
Page: 14 of 45

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Platform Lifts
  • NOT COVERED — OTC*

Seat Lift Mechanism for patient-owned furniture (E0627, E0629)

  • hip knee, muscular dystrophy or other neuromuscular diseases and is unable to rise out of any chair in the home independently or with the assistance of a caregiver AND
  • the use of the seat lift is likely to effect improvement or arrest/retard deterioration in the condition; the alternative would result in chair or bed confinement
  • Cannot be the type that operates by spring-release mechanism with a sudden, catapult-type motion that jolts the individual from a seated to standing position
LIGHTS
  • Bilirubin Blanket (E0202) - Infant must have diagnosis of hyperbilirubinemia (jaundice, elevated bilirubin level)
  • Biophotonic Therapy (light emitting diodes [LED]) (eg, Celluma) (E1399) - NOT COVERED -— experimental/investigational
  • Home-Based Ultraviolet Therapy (including ultraviolet cabinets) - See Acne Treatments Medical Coverage Policy or Ultraviolet Light/Laser Therapy for Skin Conditions Medical Coverage Policy
  • Lamp, Heating - See Cold Therapy Devices/Heating Devices/Combined Heat and Cold Therapy Devices Medical Coverage Policy
  • Phototherapy Light (bilirubin light) (E0202) - Infant must have diagnosis of hyperbilirubinemia (jaundice, elevated bilirubin level)
  • Seasonal Affective Disorder Lights/Light Therapy/Light Boxes (E0203) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
MONITORS, CARDIAC/RESPIRATORY/NEUROLOGICAL

Durable Medical Equipment (DME) Effective Date: 10/03/2023
Revision Date: 10/03/2023
Review Date: 02/02/2023
Policy Number: HUM-0429-041
Page: 15 of 45

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Apnea Monitor (E0618, E0619) - Covered for a premature infant with persistent apnea OR for an infant considered at risk for sudden infant death syndrome (SIDS)
  • Autonomic Nervous System (ANS) monitor, ambulatory (eg, BioHarness, Zephyr) (E1399) - See Autonomic Nerve Function Testing Medical Coverage Policy
  • Cardiac Monitors (including Holter monitors, cardiac event monitors, etc.) - See Ambulatory Cardiac Monitoring Devices Medical Coverage Policy
MONITORS, CARDIAC/RESPIRATORY/NEUROLOGICAL
  • CardioMems HF System - Policy See Code Compendium (Cardiovascular) Medical Coverage
  • Embrace Smartwatch (Embrace2, EmbracePlus) (sympathetic nervous system activity monitoring for seizure detection) (E1399) - Policy NOT COVERED — experimental/investigational
  • Pacemaker Monitor (E0610, E0615) - Covered for an individual with a cardiac pacemaker
  • Pulse Oximeter - See Home Oximetry Monitoring Medical Coverage Policy
  • Remote Monitoring (telemonitoring) for Congestive Heart Failure (CHF) ($9110) - NOT COVERED — not medically necessary

RESPIRATORY AIDS and SUPPLIES

  • Air Compressor (for use with nebulizer) (E0565, E0572) - Covered for treatment of asthma, chronic obstructive pulmonary disease (COPD) and other conditions where inhaled medicines are indicated
  • Cough Stimulators (Intrapulmonary Percussive Ventilation [IPV]) (eg, Impulsator) - See Airway Clearance Devices Medical Coverage Policy
  • CPAP/BiPAP (positive airway pressure Devices) - See Obstructive Sleep Apnea and Other Sleep Related Breathing Disorders Nonsurgical Treatments Medical Coverage Policy
  • Electronic Spirometer/Microspirometer (E0487) - NOT COVERED — not medically necessary
  • Heater, Respiratory Equipment (eg, for ventilator, etc.)
    • Heater, Respiratory Equipment (E1372) - Covered if individual requires oxygen flow to be heated for use with approved ventilator or other medically necessary and approved respiratory equipment
    • High Frequency Chest Compression - See Airway Clearance Devices Medical Coverage Policy

    Durable Medical Equipment (DME) Effective Date: 10/03/2023
    Revision Date: 10/03/2023
    Review Date: 02/02/2023
    Policy Number: HUM-0429-041
    Page: 16 of 45

    • IPPB (Intermittent Positive Pressure Breathing) Machine (E0500) - Covered for treatment of asthma, COPD and other conditions where inhaled medicines are indicated ONLY if a nebulizer is not effective to deliver the inhaled medications
    • Lung Assist Exsufflation Belt - See Noninvasive Home Ventilators Medical Coverage Policy
    • Mechanical Insufflation-Exsufflation Devices (eg, CoughAssist device) - See Airway Clearance Devices Medical Coverage Policy
    • Nebulizer (see below for ultrasonic type nebulizers) (E0570, E0580, E0585, A7017) - Covered for treatment of asthma, COPD and other conditions where inhaled medicines are indicated
    • Nebulizer, Battery Operated (E1399) - NOT COVERED — not medically necessary (convenience item)
    • Postural Drainage Board (E0606) - Covered for an individual who has chronic and severe pulmonary disease
    • Suction Machine (E0600) - Covered for an individual who needs assistance clearing secretions from the lungs or from a tracheostomy
    • Ultrasonic Nebulizer and High Volume/High Efficiency Nebulizers (eg, eFLOW Rapid Nebuliser System) (E0574) - Covered ONLY for delivery of tobramycin (Tobi) for an individual with cystic fibrosis who also meet the criteria above for a standard nebulizer
    • Vaporizer (E0605) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
    • Ventilator* (invasive; via an endotracheal tube or tracheostomy) (eg, LTV, Trilogy,** Versamed iVent 201, VOCSN) (E0465, E0467) - Individual must require ventilator use for respiratory support as seen with conditions such as, but not limited to, the following:
      • Chronic respiratory failure that occurs as a result of COPD; OR
      • Progressive neuromuscular diseases; OR
      • Thoracic restrictive diseases
    • For the VOCSN system (E0467) (in the invasive ventilator mode), in addition to the above conditions, an individual must also require the use of ALL functions the system offers (ventilation, oxygen delivery system [concentrator], cough assist, suction and nebulizer).

    Note: The Trilogy 100, Trilogy 200 and Trilogy Evo are currently the subject of FDA class I safety recalls.

    Note: A portable ventilator for the individual’s use outside of the home would not be considered duplicative of the original ventilator provided.

    Durable Medical Equipment (DME) Effective Date: 10/03/2023
    Revision Date: 10/03/2023
    Review Date: 02/02/2023
    Policy Number: HUM-0429-041
    Page: 17 of 45

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

    Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    For information regarding noninvasive home ventilators (including the VOCSN) please refer to Noninvasive Home Ventilators Medical Coverage Policy.
    • Vibratory Positive Expiratory Pressure Devices (eg, Acapella, Flutter, VibraLung) - See Airway Clearance Devices Medical Coverage Policy
    • Wireless Spirometer (eg, NuvoAir Air Next) (E1399) - NOT COVERED — not medically necessary

    SAFETY ITEMS

    • Bed Alarms (bed exit alarms) (A9280) - NOT COVERED — OTC*
    • Car Seats (for special needs children) (eg, Carrie Seating System, Convaid Carrot 3, IPS Car Seat, R82 Quokka, R82 Wallaroo Car Seat, Special Tomato MPS Car Seat, Spirit Car Seat [including the Spica and Spirit Plus], Traveller Plus) (E1399) - NOT COVERED — OTC*
    • Emergency Medical Alert Button System (eg, Alert1, Life Alert, Medical Guardian) — also referred to as Telephone Alert Systems ($5160 — $5162) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
    • Exersides Refraint System (upper extremity medical tubing/lines enclosure or covering device) (E0711) - NOT COVERED -— experimental/investigational
    • Grab Bars (E0241, E0242, E0246, E0700) - NOT COVERED — OTC*
    • Helmet, Protective (eg, Danmar soft shell helmet, Toppen 77 helmet) (A8000 — A8004) - Generally EXCLUDED by certificate** (not primarily medical in nature); refer to the member’s individual certificate language
    • Safety Enclosure Frame/Canopy (E0316) - Covered for use with hospital bed when criteria for the hospital bed are met AND the individual is at risk for falls or climbing

    Durable Medical Equipment (DME) Effective Date: 10/03/2023
    Revision Date: 10/03/2023
    Review Date: 02/02/2023
    Policy Number: HUM-0429-041
    Page: 18 of 45

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    Vehicular Restraint System

    • Vehicular Restraint System (eg, EZ-On vest) (E1399) - NOT COVERED — OTC*

    SELF-HELP EQUIPMENT

    • Automobile Control (E1399) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
    • Automobile Lift (E1399) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
    • Stand Aid (E1399) - NOT COVERED — OTC*
    • Standing Table (E1399) - NOT COVERED — OTC*
    • Transfer Board/Bench (E0705) - Individual must be bed- or chair-confined
    • Transfer System/Chairs (eg, Barton H250 Chair) (E1399) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

    SPEECH DEVICES

    • Speech Generating Devices - See Speech Generating Devices, Coverage Policy
    • Voice Prostheses Medical

    SUPPORTS

    • Cervical Pillows (E1399) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
    • Firefly Playpak Activity Kit (E0190) - NOT COVERED — OTC*
    • Floor Sitter (eg, Rifton Activity Chair, Special Tomato Soft Touch Sitter) (E1399) - Covered ONLY for a child with cerebral palsy or other severe neuromuscular conditions
    • P Pod Seating System/Positioning System (E1399) - NOT COVERED — OTC*
    • Positioning Pillows (E0190) - NOT COVERED — OTC*
    • Prone Board (E1399) - Covered ONLY for a child with spastic quadriplegia

    TOILET EQUIPMENT

    Bed Pan (E0275, E0276)Individual must be bed-confined

    Durable Medical Equipment (DME) Effective Date: 10/03/2023
    Revision Date: 10/03/2023
    Review Date: 02/02/2023
    Policy Number: HUM-0429-041
    Page: 19 of 45

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    TOILET EQUIPMENT

    • Bedside Commode (3-in-1 commode chair) (E0163, E0165, E0168) - Covered for an individual who meets ONE of the following criteria:
      • Bed- or chair-confined; OR
      • Cannot climb or descend stairs to reach the bathroom in the home; OR
      • Confined to the home due to a medical condition and there is no indoor bathroom (toilet)
    • Commode Chair, with integrated seat lift mechanical, electric or non- electrical (E0170, E0171) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
    • Commode Chair accessories:
      • Footrest (E0175)
      • Pail or pan, replacement (E0167)
      Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
    • Raised Toilet Seats (E0244) - NOT COVERED — OTC*
    • Toilet Rails (E0243) - NOT COVERED — OTC*
    • Toilet Seat Lift Mechanism (placed over or on top of toilet) (E0172) - NOT COVERED — OTC*
    • Toilet Seats (E1399) - NOT COVERED — OTC*
    • Toilet Trainer (E1399) - NOT COVERED — OTC*

    TRACTION EQUIPMENT

    • Standard Cervical Traction (including over-the-door, weight and pulley, home bed or freestanding) (E0840, E0850, E0855, E0856, E0860)
      • Individual must have a cervical spine (neck) impairment that requires traction equipment; the device must preclude ambulation while it is in use
    • Standard Lumbar Traction (E0890) - NOT COVERED -— experimental/investigational
    • Cervical Pneumatic Traction (eg, Pronex Pneumatic Traction Unit, ComforTrac Cervical Traction, Saunders Cervical HomeTrac) (E0849) - NOT COVERED -— experimental/investigational
    • Lumbar Pneumatic Traction (eg, Saunders Lumbar HomeTrac) (E1399) - NOT COVERED -— experimental/investigational
    • Ambulatory Traction Device (eg, Cervico2000, Vertetrac Dynamic Ambulatory 3-D Traction) (E0830) - NOT COVERED -— experimental/investigational

    Durable Medical Equipment (DME) Effective Date: 10/03/2023
    Revision Date: 10/03/2023
    Review Date: 02/02/2023
    Policy Number: HUM-0429-041
    Page: 20 of 45

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

    Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    Reverse Gravity Traction/Inversion Traction (E0941)

    WHEELCHAIRS

    • Pediatric Customized Stroller (eg, Squiggles Seating System) - See Mobility Assistive Devices (Wheelchairs) Policy Medical Coverage
    • Power Operated Vehicles - See Mobility Assistive Devices (Wheelchairs) Policy Medical Coverage
    • Roll-About Chairs - See Mobility Assistive Devices (Wheelchairs) Policy Medical Coverage
    • Scooters - See Mobility Assistive Devices (Wheelchairs) Policy Medical Coverage
    • Standing Wheelchairs, Standing Systems, Sit-to-Stand Stander/Standing Frame (eg, EasyStand Evolv, EasyStand Strap Stand) - See Mobility Assistive Devices (Wheelchairs) | Policy Medical Coverage
    • Wheelchairs (Manual and/or Electric) - See Mobility Assistive Devices (Wheelchairs) Policy Medical Coverage

    WHIRLPOOLS

    • Hydro Jet (E1399) - NOT COVERED — OTC*
    • Jacuzzi (E1399) - NOT COVERED — OTC*
    • Turbojet (E1399) - NOT COVERED — OTC*
    • Whirlpool Bath or Pump (portable or stationary) (E1300, E1310) - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
    • Whirlpool Tub, Walk-In, Portable (K1003) - Generally EXCLUDED by certificate**; refer to the member's individual certificate language

    MISCELLANEOUS

    • Apos Therapy System (eg, for knee osteoarthritis) (E1399) - NOT COVERED -— experimental/investigational
    • Aquamatic K-Pad - See Cold Therapy Devices/Heating Devices/Combined Heat and Cold Therapy Devices Medical Coverage Policy
    • Backpacks (to carry DME equipment) - NOT COVERED — OTC*
    • Bathroom (weight) Scales (E1399) - NOT COVERED — OTC*

    Durable Medical Equipment (DME) Effective Date: 10/03/2023
    Revision Date: 10/03/2023
    Review Date: 02/02/2023
    Policy Number: HUM-0429-041
    Page: 21 of 45

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

    Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    Bed-Wetting Alarms/DevicesSee Urinary Bladder Dysfunction Medical Coverage Policy
    Biofeedback Therapy DevicesSee Biofeedback Medical Coverage Policy
    Car-Ride Simulator (eg, Zed) (E1399)NOT COVERED -— experimental/investigational
    Cold Therapy DevicesSee Cold Therapy Devices/Heating Devices/Combined Heat and Cold Therapy Devices Medical Coverage Policy
    DDS 500 Lumbar Traction LSO (lumbar sacral brace)See Orthotics Medical Coverage Policy
    Defibrillators, Automated ExternalSee Cardioverter Defibrillators/Cardiac Resynchronization Therapy Medical Coverage Policy
    Defibrillators, Cardioverter, Wearable (eg, ZOLL LifeVest)See Cardioverter Defibrillators/Cardiac Resynchronization Therapy Medical Coverage Policy
    Ear Plugs (E1399) Electronic Bowel Irrigation/Evacuation System (control unit) (also referred toNOT COVERED — OTC* NOT COVERED — not medically necessary
    as pulsed irrigation bowel evacuation) and associated supplies (E0350, E0352)
    Enteral and Parenteral Feeding Pumps (Enteral and Parenteral Infusion Pumps) (B9002, B9004, B9006)Enteral feeding pumps: Covered when the individual requires enteral feedings and cannot tolerate gravity or syringe feedings OR requires a controlled rate of infusion Parenteral feeding pumps: Covered when the individual requires parenteral feedings (which always requires a controlled rate of infusion)
    Flash Switches (for toys) (E1399)NOT COVERED — OTC*
    Freespira Breathing SystemSee Biofeedback Medical Coverage Policy
    Heating PadsSee Cold Therapy Devices/Heating Devices/Combined Heat and Cold Therapy Devices Medical Coverage Policy
    Hip Positioning Kit (E0190)NOT COVERED — OTC*
    Home Cholesterol Monitor (eg, CardioChek, CholesTrak) (A9279)NOT COVERED — not medically necessary
    Home Hemoglobin Monitor (A9279)NOT COVERED — not medically necessary
    Home Modifications, per service ($5165)Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

    Durable Medical Equipment (DME) Effective Date: 10/03/2023 Revision Date: 10/03/2023 Review Date: 02/02/2023 Policy Number: HUM-0429-041 Page: 22 of 45

    Home Prothrombin Time (PT) Monitors (eg, Coag-Sense, CoaguChek, microlNR, Protime Microcoagulation system) (93792, 93793, G0248, G0249, G0250, €1399)Covered for the following indications:
    • Individual has been anticoagulated for at least 3 months prior to use of home PT monitoring device and requires long-term (greater than 1 year) anticoagulation; AND
    • Individual must have undergone educational program on anticoagulation management and the use of the device prior to its use in the home; AND
    • Self-testing with the device is limited to a frequency of once per week
    Covered when medication to be administered is covered; MUST verify that authorization has been obtained from the Medication Intake Team (MIT); if authorization has not been obtained, refer to MIT
    Lymphedema PumpsSee Lymphedema - Diagnosis and Treatment Medical Coverage Policy
    Massage Devices, including massage guns/percussion massagers (eg, Percussor massager) (E1399)NOT COVERED — OTC*
    Meniett Low-Pressure Pulse Generator Device Negative Pressure Wound TherapySee Chronic Vertigo Evaluation and Treatment Medical Coverage Policy See Negative Pressure Wound Therapy Medical Coverage Policy
    Devices Paraffin Bath (E0235)NOT COVERED — OTC*
    Peristeen Plus Transanal Irrigation System (A4459)Covered for an individual who meets the following criteria:
    • 2 years of age or older with a spinal cord dysfunction; AND
    • Neurogenic bowel dysfunction with fecal incontinence, chronic constipation, and/or time-consuming bowel management procedures; AND
    • Device must be prescribed by a healthcare provider; AND
    • Commercial Plan members: requests for continued treatment with the Peristeen system requires review by a medical director every 6 months to establish compliance and the need for

    Personal Adaptive Equipment (eg, tongs, grabbers, etc.)

    Personal Adaptive Equipment (A9281) - Personal Care Items/Utensils (eg, toothbrush, spoon, fork, hairbrush, carafe, emesis basin) (S5199) Generally EXCLUDED by certificate**; refer to the member’s individual certificate language.

    Durable Medical Equipment (DME) Effective Date: 10/03/2023
    Revision Date: 10/03/2023
    Review Date: 02/02/2023
    Policy Number: HUM-0429-041
    Page: 23 of 45

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    Recliners (E1399)
    Rectal catheter (replacement, for use w/manual pump-operated enema system) (A4453)
    RELIZORB Digestive Enzyme Cartridge (B4105)
    Scalp Hypothermia Systems (eg, Artic Cold Cap, Chemo Cold Cap, DigniCap Cooling System, Paxman Scalp Cooling System, Penguin Cold Cap Therapy System, Warrior Caps, Wishcaps)
    Scoliosis Chair (E1399)
    Sphygmomanometer (blood pressure cuff) (A4660, A4663, A4670)

    Recliners (E1399)NOT COVERED — OTC*
    Rectal catheter (replacement, for use w/manual pump-operated enema system) (A4453)Covered for those individuals who meet criteria for Peristeen Anal Irrigation System
    RELIZORB Digestive Enzyme Cartridge (B4105)NOT COVERED -— experimental/investigational
    Scalp Hypothermia Systems (eg, Artic Cold Cap, Chemo Cold Cap, DigniCap Cooling System, Paxman Scalp Cooling System, Penguin Cold Cap Therapy System, Warrior Caps, Wishcaps)See Cold Therapy Devices/Heating Devices/Combined Heat and Cold Therapy Devices Medical Coverage Policy
    Scoliosis Chair (E1399) Sphygmomanometer (blood pressure cuff) (A4660, A4663, A4670)NOT COVERED — not medically necessary Covered ONLY if prescribed by a health care practitioner for preventive services and ambulatory blood pressure monitoring is not available to confirm the diagnosis of hypertension (Refer to the member’s individual certificate language, as this may be a certificate exclusion.) All other indications/conditions: Generally EXCLUDED by certificate**; refer to the member’s
    SpineCor Brace (for scoliosis)individual certificate language See Orthotics Medical Coverage Policy
    Steam (Hydrocollator) Pack (E0225)NOT COVERED — OTC*
    Stethoscope (E1399)Generally EXCLUDED by certificate**; refer to the member’s individual certificate language
    Telephone Arm (E1399)NOT COVERED — OTC*
    Ultrasound Devices (including low frequency diathermy treatment devices), portable, for home use (including the sam [sustained acoustic medicine] Sport wearable ultrasound device, JAS Pulse Ultrasound and the NanoVibronix PainShield MD Plus hands-free device) (K1004)NOT COVERED — not medically necessary
    ViMove+ Wearable Monitor (E1399)NOT COVERED -— experimental/investigational
    Durable Medical Equipment (DME) Effective Date: 10/03/2023
    Revision Date: 10/03/2023
    Review Date: 02/02/2023
    Policy Number: HUM-0429-041
    Page: 24 of 45

    Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

    • Vitrectomy Positioning Devices (face-down systems, chairs, etc.) (eg, Comfort Solutions, Day Timer Face Down Chair, NightTimer Face-Support System) (E1399) NOT COVERED — OTC*
    • Wigs
    • Vitrectomy Positioning Devices (comfort solutions, Day Timer Face Down Chair, NightTimer Face-Support System) (E1399) - NOT COVERED — OTC*
    • Wigs - Generally EXCLUDED by certificate**; refer to the member’s individual certificate language

    *Although they may be prescribed by a health care practitioner, many DME devices are also available without a prescription and may be obtained over-the-counter (OTC) and are therefore generally excluded in the certificate. In the absence of a certificate exclusion for OTC items, those DME devices are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

    **If the member’s individual certificate does not exclude the specific DME device, the DME device would be considered not covered as an OTC item.

    Although they may be prescribed by a health care practitioner, many DME devices are also available without a prescription and may be obtained over-the-counter (OTC) and are therefore generally excluded in the certificate. In the absence of a certificate exclusion for OTC items, those DME devices are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

    Medical Alternatives Physician consultation is advised to make an informed decision based on an individual’s health needs.

    Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.