Bursitis or Chronic Osteoarthritis Would Not Generally Justify Payment for Whirlpool Bath Equipment in the Home.

DUBLIN, Ireland -- Research and Markets (http://www.researchandmarkets.com/reports/c39861) has announced the addition of Disposable Medical Supplies/Durable Medical Equipment, 3rd edition, 2006 to their offering.

This report provides hundreds of specific review criteria for supply and DME Items, alpha list with explanatory recommendation for basis to deny or approve for payment based on usual coverage 'medical necessity' determinations. This is an important UM resource tool.

What is Durable Medical Equipment?

Definition of Durable Medical Equipment

For purposes of coverage durable medical equipment is equipment which:

1) Can withstand repeated use, and

2) Is primarily and customarily used to service a medical purpose, and

3) Generally is not useful to a person in the absence of illness or injury and

4) Is appropriate for use in the home.

All requirements of the definition must be met before an item can be considered to be durable medical equipment.

a) Durability - An item is considered durable if it can withstand repeated use; i.e., the type of item normally rented. Medical supplies of an expendable nature such as incontinent pads, catheters, ace bandages, elastic stockings, surgical face masks, irrigating kits, sheets and bags are not considered durable within the meaning of the definition. Prosthetic devices, artificial arms, legs, and eyes although durable in nature fall into another reimbursement category.

b) Medical Equipment - Medical equipment is equipment primarily and customarily used for medical purposes and is not generally useful in the absence of illness or injury.

c) Investigation to determine whether the item constitutes medical equipment may be necessary. This might include the advice of local medical organizations (hospitals, medical schools, medical societies) and specialists (e.g., orthopaedics or physical medicine and rehabilitation). If the equipment is new on the market, it may be necessary prior to seeking professional advice, to obtain information from the supplier or manufacturer explaining the design, purpose, effectiveness and method of using the equipment in the home as well as the results of any tests or clinical studies that have been conducted. This is termed a new technology assessment approach.

1. Equipment Presumptively Medical - Items such as hospital beds, wheel-chairs, haemodialysis equipment, iron lungs, respirators, intermittent positive pressure breathing machines, medical regulators, oxygen tents, crutches, canes, trapeze bars, walkers, inhalators, nebulizers, commodes, suction machines and traction equipment presumptively constitute medical equipment.

2. Equipment Presumptively Non-medical - Equipment which is primarily and customarily used for non-medical purpose may not be considered medical equipment. This is true even though the item has some remote medically - related use. For example, in the case of a cardiac patient, an air conditioner might possibly be used to lower room temperature to reduce fluid loss in the patient and to restore an environment conductive to maintenance of the proper fluid balance. Nevertheless, because the primary and customary use of an air conditioner is a non-medical one, the air conditioner cannot be deemed to be medical equipment for which payment can be made.

3. Other devices and equipment used for environmental control or to enhance the environmental setting in which the patent is replaced are not considered covered durable medical equipment.

These include, for example, room heaters, humidifiers, and electric air cleaners. Equipment which basically serves comfort or convenience functions or is primarily for the convenience of a person caring for the patient, such as elevators, stairway elevators, posture chairs, and cushion lift chairs do not constitute medical equipment. Similarly, physical fitness equipment, e.g., an exercycle; first-aid or precautionary-type equipment, e.g., preset portable oxygen units; self-help devices, e.g., safety grab bars; and training equipment, e.g., speech teaching machines and Braille training texts, are considered non-medical in nature.

Necessary and Reasonable - Although an item may be classified as durable medical equipment, it may not be covered in every instance. Coverage in a particular case is subject to the requirement that the equipment be necessary and reasonable for treatment of an illness or injury, or to improve the functioning of a malformed body member. These considerations will bar payment for equipment which cannot reasonably be expected to perform a therapeutic function in an individual case or will permit only partial payment when the type of equipment furnished substantially exceeds that required for the treatment of the illness or injury involved.

Necessity for the Equipment - Equipment is necessary when it can be expected to make meaningful contribution to the treatment of the patient's illness or injury or to the improvement of his malformed body member. In most cases the physician's prescription for the equipment will be sufficient to establish that the equipment service is purpose.

Tests for Reasonableness of the Equipment

1. Would the expense of the item be clearly disproportionate to the therapeutic benefits which could ordinarily be derived from use of the equipment?

2. Is the item substantially more costly than a medically appropriate and realistically feasible alternative pattern of care?

3. Does the item serve essentially the same purpose as equipment already available to the patient?

The following example points up the applicability of these reasonableness guidelines:

EXAMPLE: The median price of standard whirlpool bath equipment is about $600 plus plumbing expenses necessary to install it in the patients home. Coverage of such equipment in the patients home should be limited to those cases where it is prescribed for conditions where the whirlpool bath can be expected to provide substantial therapeutic benefit justifying its cost.

For example, bursitis or chronic osteoarthritis would not generally justify payment for whirlpool bath equipment in the home since it would not be reasonable to expect that a whirlpool bath would be significantly more beneficial than a normal warm bath.

Moreover, where the patient is not homebound, payment for this item in the patient's home should be restricted to the cost of providing the service elsewhere, e.g., an outpatient department of a participating hospital, if that alternative is less costly.

Payment Consistent with Necessary and Reasonable Determinations - Where a claim is filed for equipment containing features of an aesthetic nature or features of a medical nature which are not required by the patients condition (i.e., not medically necessary) or where there exists a reasonably feasible and medically appropriate alternative pattern of care which is less costly for the equipment or alternative treatment which meets the patients medical needs.

The costs of needed adjustment or repair of equipment supplied as a covered benefit will be covered. If a warranty is in effect, the equipment must be adjusted, repaired or replaced under the terms of the warranty.

For more information visit http://www.researchandmarkets.com/reports/c39861