The Centers of Medicare and Medicaid Services defines durable medical equipment (DME) as equipment meeting the following:

• Can withstand repeated use
• Generally, is not useful to a person in the absence of an illness or injury
• Has an expected lifetime of at least three years

Clinical Guideline Coverage Criteria

Harvard Pilgrim Health Care uses guidance from the Centers for Medicare and Medicaid Services (CMS) for coverage determinations for its Medicare Advantage plan members. CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs) and documentation included in the Medicare manuals are the basis for coverage determinations where available.

For Harvard Pilgrim Health Care Medicare Advantage plan members, the following criteria is used for any DME over $500:

• NCD - Durable Medical Equipment Reference List (280.1) (cms.gov).

In addition to this NCD list, the Plan may utilize CMS guidance through New Hampshire based LCDs, LCAs, and other

Durable Medical Equipment Coverage Determinations

for DME services including but not limited to the below:

• Oral appliances for OSA: LCD - Oral Appliances for Obstructive Sleep Apnea (L33611) (cms.gov) and Article - Oral Appliances for Obstructive Sleep Apnea - Policy Article (A52512) (cms.gov)
• Pneumatic Compression Devices: in addition to the NCD, the following is also used LCD - Pneumatic Compression Devices (L33829) (cms.gov) and Article - Pneumatic Compression Devices - Policy Article (A52488) (cms.gov)
• Power mobility devices and accessories: in addition to the NCD, the following is also used LCD - Power Mobility Devices (L33789) (cms.gov), Article - Power Mobility Devices - Policy Article (A52498) (cms.gov), LCD - Wheelchair Options/Accessories (L33792) (cms.gov), and Article - Wheelchair Options/Accessories - Policy Article (A52504) (cms.gov)
• Speech generating devices: in addition to the NCD, the following is also used LCD - Speech Generating Devices(SGD) (L33739) (cms.gov) and Article - Speech Generating Devices (SGD) - Policy Article (A52469) (cms.gov)
• Positive Airway Pressure (PAP) devices- CPAP and BiPAP: in addition to the NCD, the following is also used: LCD - Respiratory Assist Devices (L33800) (cms.gov), Article - Respiratory Assist Devices - Policy Article (A52517) (cms.gov), LCD - Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea (L33718) (cms.gov), and Article - Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea - Policy Article (A52467) (cms.gov)

Limitations

Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers durable Medical Equipment (DME) as not medically necessary for all other indications.