Consumable Medical Supplies

Reimbursement Policy:

Consumable Medical Supplies

Effective Date:

May 1, 2016

Last Reviewed Date:

February 23, 2023

Purpose:

Provide clarification of the standard Horizon benefit contract exclusions relative to consumable medical supplies using specific codes and examples.

Scope:

All plans/products that include the following standard Horizon benefit contract exclusions are considered in scope.

Non-HMO Individual Consumer and Small Group Employer (2-49 employees) plans:

• Non-prescription drugs or supplies, except
  • insulin needles and syringes and glucose test strips and lancets;
  • colostomy bags, belts and irrigators; and
  • as stated in this Policy for food and food products for inherited metabolic diseases.
• Personal convenience or comfort items including, but not limited to, such items as TV's, telephones, first aid kits, exercise equipment, air conditioners, humidifiers, saunas, hot tubs.
• Self-administered services such as: biofeedback, patient-controlled analgesia on an Outpatient basis, related diagnostic testing, self-care and self-help training.
• Services or supplies that are not furnished by an eligible Provider.

HMO Individual Consumer and Small Group Employer (2-49 employees) plans:

• Non-prescription drugs or supplies, except
  • insulin needles and syringes and glucose test strips and lancets;
  • colostomy bags, belts and irrigators; and
  • as stated in this Policy for food and food products for inherited metabolic diseases.
• Personal convenience or comfort items including, but not limited to, such items as TV's, telephones, first aid kits, exercise equipment, air conditioners, humidifiers, saunas, hot tubs.
• Self-administered services such as: biofeedback, patient-controlled analgesia on an Outpatient basis, related diagnostic testing, self-care and self-help training.

Non-HMO Large Group Employer (51+ employees) plans:

• Ancillary charges connected with self-administered services such as: patient-controlled analgesia; related diagnostic testing; self-care; and self-help training
• Consumable medical supplies
• Non-Medical equipment which may be used chiefly for personal hygiene or for the comfort or convenience if a covered person rather than for medical purpose. This includes: air conditioners, dehumidifiers, purifiers, saunas, hot tubs; televisions, telephones, first aid kits, exercise equipment, heating pads; and such similar supplies which are useful to a person in the absence of Illness or Injury.
• Personal comfort and convenience items.

HMO Large Group Employer (51+ employees) plans:

• Self-administered services such as: biofeedback, patient-controlled analgesia, related diagnostic testing, self-care and self-help training.
• Non‑medical equipment which is primarily for personal hygiene or for comfort or convenience rather than for a medical purpose, including air conditioners, dehumidifiers, purifiers, heating pads and similar supplies which are useful to a person in the absence of Illness or Injury or other condition.
• Services and supplies for the personal convenience or comfort of the Member, including, but not limited to, such items as televisions, telephones, first aid kits, exercise equipment, air conditioners, humidifiers, saunas and hot tubs.

Policy:

Consumable medical supplies are non-durable medical supplies that cannot withstand repeated use, are usually disposable, and are generally not used in the absence of illness or injury. They include, but are not limited to, bandages, antiseptics, and skin preparations and personal protective equipment (PPE) such as masks (community and medical/surgical), goggles, face shields/safety visors, respirators (N95 and filtering face piece), gloves (examination and surgical), gowns, garments, coveralls, and clean air suits.

Additionally, PPE products used while examining or treating a patient in an Office, Urgent Care Center; Surgical Center; Home or other setting will not be considered for separate reimbursement.

Horizon BCBSNJ will not reimburse claims submitted for consumable medical supplies including, but not limited to, items represented by the HCPCS codes below, and as consistent with the general exclusion language present in all member benefit contracts that include those exclusions detailed in the Scope section above.¹

¹ As of the Effective Date, systemic claims coding was reviewed and confirmed to be consistent with this Policy.

The codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued, until such time as the Policy is reviewed and updated to reflect the new or amended coding.

Procedure:

Maintain the plan general exclusion (PGE) edit on consumable medical supplies, including but not limited to the HCPCS codes listed in the examples above.

In denied instances where the provider is participating, it is generally not expected that the provider will bill the member for these consumable items, however, if they do, the member’s liability shall be up to the provider’s charge.

In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Limitations and Exclusions:

Consumable medical supplies provided in conjunction with DME are covered if the supplies are necessary for the function of the equipment and the equipment is covered under the plan. Examples include ostomy and ventilator supplies.

While reimbursement is considered, payment determination is subject to, but not limited to:

• Group or Individual benefit
• Provider Participation Agreement
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
• Mandated or legislative required criteria will always supersede.

The following categories of consumable medical supplies may be eligible for coverage according to federal or state mandates, or current industry standards:

• Diabetes supplies, including alcohol wipes
• Surgical wound care supplies, including gauze pads, wound cleansers, and compression bandages
• Inpatient hospital services;
• Outpatient hospital facility services;
• Home health services;
• Breast reconstruction and breast prostheses

History:

1/10/2018: Removed deleted HCPCS code A4466
7/27/2020: Added HCPCS codes A4927, A4928, A9270, A9999. Updated policy section on PPE equipment
2/28/2022: Corrected descriptions of codes A6457, A9270 and A9273 within Policy: section table.

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