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General Coverage Scope of Coverage Level of Coverage Durable Medical Equipment (DME), Prosthetic Appliances and Orthotic Devices Durable Medical Equipment means devices and equipment ordered by a practitioner for the treatment of a specific medical condition which:  Can withstand repeated use for a protracted period of time;  Are primarily and customarily used for medical purposes;  Are generally not useful in the absence of illness or injury; and  Are usually not fitted, designed or fashioned for a particular person’s use.

DME intended for use by one person may be custom- made or customized. Includes hospital beds and accessories, oxygen and oxygen supplies, pressure pads, volume ventilators, therapeutic ventilators, nebulizers and other equipment for respiratory care, traction equipment, walkers, wheelchairs and accessories, commode chairs, toilet rails, apnea monitors, patient lifts, nutrition infusion pumps, ambulatory infusion pumps and other miscellaneous DME.

DME coverage includes equipment servicing (labor and parts). Examples include, but are not limited to:

Fitted/Customized leg brace Not fitted/Customized cane

Prosthetic arm

Wheelchair

Footplate

Crutches

Prosthetic Appliances are those appliances and devices ordered by a qualified practitioner which replace any missing part of the body. Covered without limitation except that there is no coverage for cranial prosthesis (i.e. wigs) and dental prosthesis, except those made necessary due to accidental injury to sound, natural teeth and provided within twelve months of the accident, and except for dental prosthesis needed in treatment of congenital abnormality or as part of reconstructive surgery. Orthotic Devises are those devices which are used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body. No limitations on orthotic devices except that devices prescribed solely for use during sports are not covered. Therapeutic Services Ambulatory radiation therapy, chemotherapy, injections and medications provided at time of therapy (i.e. chemotherapy) will also be covered. No limitations. These therapies must be medically necessary and under the supervision or referral of a licensed physician. Short term physical and occupational therapies will be covered when ordered by a physician. No procedure or services considered experimental will be reimbursed. Hemodialysis Determination of the need for services and whether home-based or facility-based treatment is appropriate. Speech and Hearing Services Including Hearing Aids Hearing examinations to determine the need for corrective action and speech therapy performed by an audiologist, language pathologist, a speech therapist and/or otolaryngologist. One hearing examination per calendar year is covered. If an auditory deficiency requires additional hearing exams and follow-up exams, these exams will be covered. Hearing aids, including batteries and repairs, are covered. If medically necessary, more than one hearing aid will be covered.

Covered speech therapy services are those required for a condition amenable to significant clinical improvement within a two-month period, beginning with the first day of therapy.