DME Checklist of Information Needed from Providers

Please note: This communication applies to Healthy Blue + Medicare℠ (HMO D-SNP) offered by Blue Cross and Blue Shield of North Carolina (Blue Cross NC).

Blue Cross NC wants to help ensure Medicare Advantage members receive the DME they are eligible to receive under CMS guidelines as soon as that equipment is needed. When requesting DME for your patients, our members, please include the information below to give our physiatrist and other clinical reviewers a complete picture of your patients’ status and needs. This will help ensure a timely response from Blue Cross NC; reduce the need for additional phone calls, faxes, emails and appeals; and deliver the requested DME to your patients as soon as possible.

Manual and Power Wheelchair Repair: 

1. Date of purchase for wheelchair
   
2. Payer of wheelchair
3. Make, model and serial number of current chair
4. What repairs are needed, and why are they needed?

Manual and Power Wheelchair Replacement:

1. Date of purchase of wheelchair being replaced
   
2. Payer of current wheelchair being replaced (commercial, traditional Medicare, Medicaid)
3. Make, model and serial number of current chair
4. Estimate of repairs needed for current wheelchair to be functional
5. If current wheelchair cannot be repaired, why not?
6. If member’s functional needs have changed, document why current wheelchair is not meeting functional needs (for example, new medical, surgical, neurological event, new injury, etc.)

New Manual or Power Wheelchair Requests:

1. How does member currently complete activities of daily living?
   
2. How does member currently meet mobility needs?
3. Does member have a cane, walker, manual wheelchair or power wheelchair? Is it working for them? If no, why not?
4. Cognitive status of the member — Are they safe to operate a motorized vehicle independently?
5. Need face-to-face physician evaluation for all manual and power wheelchairs
6. Need seven element order for power wheelchair (See National Coverage Determination [NCD] 280.3 or Local Coverage Determination [LCD] L33789 below for details.)
7. Need physical therapy/occupational therapy/assistive technology practitioner/rehab doctor evaluation for group [two/three] power wheelchair
8. Where does member live (for example, home, dually certified skilled nursing facility [SNF], assisted living facility [ALF), homeless)?
9. Does member live in dually certified SNF? If so, is wheelchair paid for by SNF and not by Medicare? (Check QCOR site: https://qcor.cms.gov.)
10. Need home assessment completed — Does the home allow the wheelchair to fit into the areas that the member needs to go?

Wheelchair Components Requests:

1. Powered elevating leg rests — need physical exam of legs showing swelling of the extremities or knee contracture
   
2. Powered recline — Does the member perform self-catheterization? Does the patient have spasticity?
3. Powered tilt — Can the member perform pressure relief? Does the member have pressure ulcers now or a history of pressure ulcers?

Capped Wheelchair Rentals:

1. Date of initial approval of wheelchair
   
2. Payer of wheelchair
3. Months left to be approved for total of 13 months of capped rental

Helpful CMS links:

• NCD for Mobility Assistive Equipment (280.3)
  
• LCD: Power Mobility Devices (L33789)
• LCD: Wheelchair Options/Accessories (L33792)
• LCD: Wheelchair Seating (L33312)
• Additional information required for wheelchair repair requests: Medicare Benefits Policy Manual, Chapter 15, Section 110 — Durable Medical Equipment

E0466 Noninvasive Home Ventilators:

• Ensure medical records document:
  
  • Member’s medical history of pulmonary problems.
  • How member’s current respiratory needs have been managed (for example, oxygen, CPAP, BIPAP, ventilator).
  • Why current management is not sufficient.
• If a continuation is being requested, then provide:
  • Date of initial noninvasive ventilation (NIV) approval.
  • Which insurer approved the initial NIV approval.
  • Doctor’s note/compliance report showing the member is using the ventilator as ordered.

Helpful CMS link:

• LCD: Respiratory Assist Devices (L33800)
  

K0606 Lifevest:

1. Provide physician medical records to support request for lifevest
   
2. Provide documented ECHO report within one month of dates of service requested for both new and continuation requests
3. Provide plan of care for future implantation of defibrillator

Helpful CMS link:

• LCD: Automatic External Defibrillators (L33690)
  

E0784 Insulin Pump:

1. Results of C-peptide taken at same time as fasting blood glucose; must provide reference range from the lab
   
2. If no C-peptide results, then can submit beta-cell antibody result

Helpful CMS link:

• LCD: External Infusion Pumps (L33794)
  

Wound Pump:

1. Date of wound pump application
   
2. Where the wound pump was applied (for example, in hospital, SNF, at home) 
3. Was it applied on a surgically created wound?
4. Measurements of wound
5. Progress of wound measurements for continuation request
6. Note that per Medicare, wound pumps have a four-month cap — Any requests beyond four months will be denied and must be submitted for an overturn via the appeals process

Helpful CMS link:

• LCD: Negative Pressure Wound Therapy Pumps (L33821)
  

Common Dressing Supply Requests:

• If requesting more than the Medicare allowable quantity, document why more than the allowable quantity is needed
  

Helpful CMS links:

• LCD: Tracheostomy Care Supplies (L33832)
• LCD: Surgical Dressings (L33831)
• LCD: Ostomy Supplies (L33828)

Braces:

1. Physician’s note with physical exam of affected region needing brace
   
2. Imaging of affected area can be submitted to support the need for brace
3. Only providing a supplier/vendor note with physical exam is not approvable per Medicare guidelines

Helpful CMS links:

• LCD: Knee Orthoses (L33318)
  
• LCD: Ankle-Foot/Knee-Ankle-Foot Orthosis (L33686)
• LCD: Spinal Orthoses: TLSO and LSO (L33790)

Bone Stimulators:

• For long bone fracture nonunion, need two X-rays, dated 90 days apart, showing no healing of long bone fracture
  
• For joint fusion nonunion, need documentation of nonhealing fusion site nine months after joint fusion surgery
• For spinal fusion surgery:
  • Documentation of nonhealing fusion site nine months after spinal fusion surgery
  • Documentation of spinal fusion surgery at three or more spinal levels
  • Documentation of repeat spinal fusion surgery in the same region

Helpful CMS link:

• LCD: Osteogenesis Stimulators (L33796)