Policy and Procedure Name:	Durable Medical Equipment (DME)
Policy #:	MP-4-01
Code/Rule Reference:	R.C. 4123.66; O.A.C. 4123-6-02.2, 4123-3-15, 4123-6-07, 4123-6-16.2, and 4123-6-25
Effective Date:	06/06/14
Approved:	Freddie Johnson, Esq., Chief of Medical Services (signature on file)
Origin:	Medical Policy
Supersedes:	All medical policies and procedures, directives or memos regarding durable medical equipment that predate the effective date of this policy.
History:	Rev. 07/16/13; New 09/21/12
Review date:	06/06/19

 

 

I. POLICY PURPOSE

 

The purpose of this policy is to ensure that the Bureau of Workers Compensation (BWC) reimburses for equipment meeting the criteria of Durable Medical Equipment (DME) when the equipment is reasonably related to and medically necessary for the treatment of an authorized condition(s) in a claim.

 

II. APPLICABILITY

 

This policy applies to all BWC and Managed Care Organization (MCO) staff having the responsibility of authorizing DME rental/purchase.

 

III. DEFINITIONS

 

Durable Medical Equipment: Equipment which is suitable for use outside of a medical facility and that:

• can withstand repeated use;
• can primarily and customarily serve a medical purpose;
• generally is not useful to a person in the absence of illness or injury;
• is appropriate for use in the home; and
• does not include disposable items.

Examples of DME include walkers, canes, crutches, hospital beds, bedside commodes, breathing machines, wheelchairs, power operated vehicles, etc.

 

IV. POLICY

 

A.     It is the policy of BWC to reimburse providers for:

1.    DME purchases or rentals up to the purchase price, when deemed necessary and reasonable using the criteria outlined in State, ex rel. Miller v. Indus. Comm., 71 Ohio St.3d 229 (1994,);

2.    DME purchased through a BWC certified supplier or in the absence of a certified provider, a supplier meeting the minimum credentialing standards for DME suppliers set forth in OAC 4123-6-02.2; and

3.    A single DME item of specified use, unless medical documentation substantiates the need for multiple items of the same use. This shall be evaluated on a case-by-case basis.

 

B.    It is the policy of BWC to require that:

1.    MCOs ensure, in accordance with the Provider Reimbursement Manual, that providers have obtained prior authorization for the purchase of DME costing $250 or more.

2.    MCOs obtain prior authorization from BWC for the rental of DME when the total cost of the rental is anticipated, or has the probability, to exceed eighty percent (80%) of the purchase price of the DME.

 

C.   Special considerations for specific equipment

1.    Manual Wheelchairs

a.    A wheelchair is covered when the injured worker’s (IW) condition is such that without a wheelchair she/he would be bed or chair bound.

b.    Upgrades beneficial solely in allowing the IW to perform leisure or recreational activities are generally not covered.

c.    Specially sized wheelchairs are reimbursable when documentation supports the need, such as for IW’s with slender or obese builds, or narrow doorways.

d.    Information submitted by the DME supplier must be corroborated by documentation in the IW’s medical records and available upon request.

2.    Power Operated Vehicles (POV)/Motorized Wheelchairs

a.    Medical Requirements:

i.      Requests must be from a physician in one of the following specialties:

a)    Physical Medicine;

b)    Orthopedic Surgery;

c)    Neurology; or

d)    Rheumatology.

ii.     If an above listed specialist is more than one day’s round trip from the IW’s home, the physician of record may make the request.

iii.    Requests with insufficient medical evidence to support the need for a POV requires a Justification of Medical Necessity for Seating/Wheeled Mobility form / C-190 or equivalent from a physician listed above, or an Occupational Therapist (O.T) or Physical Therapist.

iv.   Require an occupational therapy (O.T) evaluation by a BWC certified Occupational Therapist not employed by the DME vendor documenting type of POV/wheelchair needed, medical indications, necessary options/accessories, and appropriate vehicle size to accommodate mobility throughout IW’s living quarters.

b.    Physical/mobility requirements:

i.      The IW’s movement throughout the home must not be possible without the POV

ii.     The IW must have adequate trunk stability to ride in a POV and safely transfer in and out of a POV.

iii.    The IW must be unable to operate a manual wheelchair, but be capable of safely operating the controls of a POV.

 

V. PROCEDURE

 

A.    Requirements for the purchase or rental of DME

1.    The MCO shall process DME that is reimbursable via the fee schedule in accordance with:

a.    The C-9 Processing policy and procedure; or

b.    The Claim Reactivation policy and procedure.

2.    If the MCO cannot process the DME pursuant to procedure A. 1. a-b, then they shall process DME provided by a BWC-certified provider according to the Override Process policy and procedure.

B.    Procedural requirements for a POV

3.    Prior to authorizing the purchase of a POV, the MCO shall discuss with the BWC catastrophic nurse if home modifications will be necessary to accommodate the POV/motorized wheelchair.

4.    The MCO shall ensure that it receives a signed itemized quote from the DME vendor including all features, accessories and the inclusion of a rental at no charge for repairs occurring during the warranty period of the POV/wheelchair is required.

5.    The MCO shall call the IW after the delivery of the POV/wheelchair to ensure the POV/wheelchair comfortably accommodates the IW, fits inside the home and has the options medically necessary for the IW to perform activities of daily living. If there are issues, the MCO may schedule a post delivery O.T. follow-up evaluation.