We’re aligning our commercial billing and coding requirements for durable medical equipment (DME) supplies to those defined by the Centers for Medicare and Medicaid Services (CMS).
The following policies – which establish reimbursable limits / frequency guidelines pulled directly from CMS local coverage determinations (LCD) and coding articles – will go into effect on Aug. 1, 2024:
Exceptions & appeals
Any exceptions to these policies will be specifically outlined in our Provider Manual or in our commercial medical policies. Providers may appeal denials for units exceeding the defined limits – appeals must be supported with medical record documentation.
Medicare & Medicaid
For Medicare claims, we’ll continue to follow CMS-defined guidelines as outlined by the Medical Affairs Committee (MAC) in national coverage determinations (NCD), LCD and Articles. Our Medicaid products will continue to follow MDHHS- and CHAMPS-defined guidelines.
See our Provider Manual’s payment policies page and continue to monitor these PriorityActions emails for additional policy alignment information.