Insurance

Overview:

In cases where a more specific HCPCS code is not available, a product may be billed using E1399, durable  medical equipment, miscellaneous. In order for durable medical equipment to be covered or reimbursed, many third-party payers require the equipment to be:

  • Prescribed by a physician
  • Durable
  • Medically necessary 

Medical Necessity/Reasonableness:

Sometimes third-party payers believe an item provided to a customer is not “medically necessary” or “reasonable” and payment for the equipment may be denied. “Medical necessity” claims for equipment may be turned down because:

  • Therapeutic function is questioned
  • Equipment is believed to only provide partial therapeutic benefit
  • The equipment substantially exceeds what is needed for treatment - or too expensive

Check for “Medical Necessity”:

A physician’s order and/or documentation of medical necessity is required to be completed and signed by the physician for every DME claim. The physician order and/or documentation of “medical necessity” should include, at a minimum, the following information or documentation: 

  • Patient's Diagnosis
  • Patient's Prognosis
  • Clinical need for the equipment
  • Duration of medical need (six months or longer typically receives special review)

Include product literature as a description of the equipment and instructions for intended use and indications. Any available clinical studies are may be helpful in providing a detailed description of the clinical application of the item. Administrative information, such as suggested retail cost of the item, supplier ID, address, and telephone number are also necessary.

Claims can be denied if any of the following statements are true:

  • Product cost of the item outweighs the benefits
  • A “clearly disproportionate” expense
  • Alternative therapy is not medically appropriate and/or reasonably easy to provide
  • The patient previously purchased a device that has the same purpose

Suggested Documentation:

The following materials on the SinuPulse Elite® Advanced Sinus Irrigation System are available from Health Solutions Medical Products Corporation:

  • Nasal/Sinus Irrigation Instructions
  • Frequently Asked Questions about Pulsatile Irrigation
  • Mechanical/Electrical Instructions
  • SinuPulse Elite® Sell Sheet and Product Description
  • Physician reference and bibliography

Note:

Inclusion or exclusion of a procedure code for a specific product or supply does not imply any health insurance coverage or reimbursement policy. All referenced information and codes were taken from HCPCS.