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Regence BlueShieldAll Plans · Coverage · Medical Policy · OrthopedicsMedium impact

Durable Medical Equipment, Prosthetic and Orthotic Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment

Effective date
Oct 1, 2026
Identified
Jun 16, 2026

Summary

Medical Policy DME75 covers replacement, repair, and non-routine maintenance of durable medical equipment, prosthetics, and orthotics, and it is effective October 1, 2026. Replacement of member-owned DME may be considered medically necessary when the item still is medically necessary and it has been lost, stolen or irreparably damaged, or when clinical evidence shows a significant change in the individual's condition, the item can no longer meet the individual's functional needs, and replacement is the least costly option. Irreparably worn items that have exceeded the minimum five-year reasonable useful lifetime may also be replaced. Repair may be considered medically necessary for member-owned equipment when the repair is needed to make it serviceable, the item is not under manufacturer or supplier warranty, and the supplier uses the least costly option. Replacement is considered not medically necessary for oxygen equipment during its reasonable useful lifetime, rented equipment, equipment damaged by member abuse, neglect or intentional damage, and items covered under manufacturer warranty. Upgrades with features that exceed the member's functional needs, routine maintenance, and back-up or duplicate items are considered not medically necessary.

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What to do

Action · 11 steps
01Effective October 1, 2026: Billing team, before billing a replacement, confirm that the item still is medically necessary and that the supplier has documentation in the medical records or chart notes supporting the continued need.
02For lost items, include a written explanation of the circumstances of the loss.
03For stolen items, provide a police report.
04For irreparably damaged or irreparably worn items, include verification of how the equipment was damaged, or for wear a repair evaluation that documents what is wrong with the equipment down to the part level, plus a physician's order and/or new Certificate of Medical Necessity (CMN).
05For a replacement due to change in the individual's condition, document what has changed for the member, why the existing equipment is inadequate, and include a physician's order and/or new CMN.
06For repairs, include a repair evaluation, show the part is medically or reasonably necessary to restore the equipment to a serviceable condition, and include a statement that the item or part is not covered under manufacturer warranty.
07Leave out parts that are not reasonable or medically necessary from the repair or replacement estimate.
08Before replacing equipment, repairs may be attempted to make the item serviceable until it becomes irreparable.
09Documentation is not required with every claim but may be requested for audit.
10Do not bill replacement or repair of items covered under manufacturer or supplier warranty, rented equipment, or oxygen equipment replacement during its reasonable useful lifetime, because the policy considers these not medically necessary.
11An item that meets the medically necessary criteria is not guaranteed reimbursement, because claim adjudication is subject to claim processing guidelines and provider contracts.

Codes mentioned

E0467

Original notice

Durable Medical Equipment, Prosthetic and Orthotic Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment
beonbrand.getbynder.com · Always check the source before changing claims.
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Related policy hubs

Regence BlueShield policiesOrthopedicsCode E0467

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