and Procedure Name:
Medical Equipment (DME)
4123.66; O.A.C. 4123-6-02.2, 4123-3-15, 4123-6-07, 4123-6-16.2, and 4123-6-25
Johnson, Esq., Chief of Medical Services (signature on file)
medical policies and procedures, directives or memos regarding durable
medical equipment that predate the effective date of this policy.
07/16/13; New 09/21/12
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.
This policy applies to all BWC and Managed Care
Organization (MCO) staff having the responsibility of authorizing DME
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;
- does not include disposable items.
of DME include walkers, canes, crutches, hospital beds, bedside commodes,
breathing machines, wheelchairs, power operated vehicles, etc.
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
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.
considerations for specific equipment
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.
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.
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
i. Requests must be
from a physician in one of the following specialties:
c) Neurology; or
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
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.
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
iii. The IW must be
unable to operate a manual wheelchair, but be capable of safely operating the
controls of a POV.
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
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
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.