What considerations are part of an evaluation of Reasonableness and Necessity? Identify and explain how an item may meet the definition of DME and yet not be covered by the plan

Question

What will be an ideal response?

Answer 1

Answer:
Two things to be considered are:
a. Reasonableness. This evaluates the soundness and practicality of the DME approach to therapy, including such factors as:
1. Is the need for the unit based on failures of other, less costly approaches? For example, if the patient tried an inexpensive transfer board and was unsuccessful, then a trapeze which is more expensive would be a better option for the patient to transfer himself out of the bed.
2. Have more conservative means been attempted? Conservative relative to DME is something like using a hot pack for muscle relaxation versus a less conservative method of an electrical stimulation unit.
3. What benefits will be derived from the unit? If DME will bring the patient's functioning back to the previous level, it is usually considered beneficial. However, if the equipment is just a trial, but not likely to really progress the patient along in functioning, it isn't considered a benefit.
4. Do the benefits justify the expense?
b. Necessity. Equipment is necessary when it is expected to make a meaningful contribution to the treatment of the patient's illness or injury or to the improvement of the functioning of a malformed body part. Physicians tend to prescribe equipment based on a variety of reasons including:
1. Familiarity. The physician is familiar with a particular piece of equipment. Other less expensive, more effective means of treatment or equipment may be available.
2. Current popularity. As with clothing fashions, treatment and equipment popularity runs in cycles. Patients may even request the use of some pieces of equipment because it is hyped by the news media or some other medium. The particular equipment may not be the best or least expensive treatment available.
3. Monetarily beneficial. Some equipment suppliers provide monetary inducements to physicians who use their equipment. Therefore, some physicians may routinely prescribe certain equipment based on this factor.