La. Admin. Code tit. 40, § I-4111 - Durable Medical Equipment

A. Durable medical equipment (DME) refers to those items which can withstand repeated use, are primarily used to serve a medical purpose, are generally not useful to a person in the absence of illness, injury or disease, and are appropriate for use in the claimant's home.

1. Covered Services. The carrier/self-insured employer reimburses for the purchase or rental of certain medical equipment and accessories and the purchase of certain medical supplies for the claimant's use in a noninstitutional setting. Supplies and equipment for nursing home claimants are restricted by the terms of any negotiated agreement between the nursing home and the carrier/self-insured employer, except as detailed herein. All items must be prescribed by the claimant's treating physician.

Note: Allowances pertaining to oxygen and other respiratory equipment and services can be found in both this manual and the respiratory services manual. procedure codes and billing instructions for braces and supplies related to prosthetic devices may be found in the manual for prosthetic/orthopedic equipment. hearing aid information is found in the hearing aid equipment and services manual.

2. Noncovered Services. In general, only those supply and equipment items listed in the section of this manual entitled "maximum allowances" will be reimbursed. The use of otherwise unlisted HCPCS codes may be covered when medical necessity is documented.

3. Nonlisted Items and Individual Consideration. Occasionally, there may be a workers' compensation claim where the HCPCS code either does not appear on the schedule of maximum allowances or is designated as "by report (BR)." In these instances, where medical necessity has been documented, the carrier/self-insured employer should contact three DME Suppliers in the geographic area from which the claim originated and obtain charge information for the specific HCPCS code billed. The carrier will use the average of the three responses as the maximum allowance for the specific HCPCS code. This procedure may be repeated when necessary for other codes which fall into this category.

Notes

La. Admin. Code tit. 40, § I-4111

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.