Obtain and transmit a complete Standard Written Order (SWO)

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted; a new prescription from the treating practitioner is required each time a new device or repair is requisitioned. The SWO must include member name/ID, order date, description of the item (HCPCS code, HCPCS narrative, or brand/model), each separately billed option/accessory or supply with HCPCS and quantity, treating practitioner name and NPI, and the treating practitioner’s signature.

• SWO required before supplier billing; claim billed without SWO will be denied as not medically necessary.
• SWO must list HCPCS code or brand/model and each separately billed option/accessory with HCPCS and quantity.
• A new prescription is required for each new device or repair.

Bill using HCPCS only when criteria support coverage; note specific non‑covered HCPCS

HCPCS in the policy are covered only when the selection criteria are met; some HCPCS are explicitly listed as not covered for indications in this policy (examples provided). Providers should reference the HCPCS list when ordering and billing to ensure the code is valid for the member’s indication.

• HCPCS codes are covered if selection criteria are met (see HCPCS list in policy).
• Examples of HCPCS listed as not covered for CPB-listed indications include E0117, E0144, E0152, and E0156.

Confirm payer-specific prior authorization rules; follow appendix billing guidance

The policy does not state an explicit universal prior authorization requirement; however, providers should obtain prior authorization when required by the payer for listed DME devices and follow appendix billing consolidation guidance for walkers and replacement parts.

• No explicit PA requirement stated in these sections of the policy.
• Appendix clarifies when replacement parts/accessories are included in the allowance for a primary walker item.

Document that the requested device type will sufficiently resolve the mobility deficit

Document in the treating practitioner’s medical record that the mobility deficit can be sufficiently resolved by the device type requested (e.g., cane/crutch versus walker) and that the member can safely use the requested device.

• Coverage requires the functional mobility deficit be sufficiently resolved by the requested device type.
• Provider must document the member’s ability to safely use the device.

Provide sufficient clinical documentation in the medical record (supplier forms alone insufficient)

Ensure the medical record contains sufficient clinical information to support all applicable coverage criteria; supplier-prepared statements or practitioner attestations alone are insufficient to establish medical necessity.

• Records must substantiate the medical necessity information on supplier forms or attestations.
• Supplier or provider records with a financial interest in the claim are not sufficient by themselves.

Document the three medical‑necessity components (mobility limitation, safe use, expected improvement)

Include documentation of the member’s significant mobility limitation, ability to safely use the device, and the expected functional improvement from the device in the medical record; the policy bases medical necessity on these three components.

• Document the specific MRADL(s) affected and how the device addresses the deficit.
• Document anticipated functional benefit and safe use capability.

Risk of denial if SWO not communicated to supplier before billing

Claims billed without a Standard Written Order (SWO) first communicated to the supplier will be denied as not medically necessary; suppliers billing without a completed SWO should expect denial.

• If the supplier bills for an item without first receiving a completed SWO, the claim shall be denied as not medically necessary.
• SWO must be communicated to the supplier prior to claim submission.

Avoid HCPCS specifically listed as not covered for CPB indications

HCPCS codes listed in the policy as 'not covered for indications listed in the CPB' (for example E0117, E0144, E0152, E0156) may lead to denial when billed for those CPB‑listed indications; avoid using those codes for excluded indications.

• E0117 — Crutch, underarm, articulating, spring assisted.
• E0144 — Walker, enclosed, four sided framed, rigid or folding, wheeled with posterior seat.
• E0152 — Walker, battery powered (Sully Walker).
• E0156 — Seat attachment, walker.

Do not bill Column II walker accessories separately when provided with primary walker

When billing a walker with Column II items provided at the same time, include those Column II items in the allowance for the Column I primary walker item and do not submit separate claims for them.

• Items in Column II are included in the allowance for the corresponding Column I item and must not be billed separately at the time of billing the Column I item.
• Appendix Table lists replacement handgrips, tips, brake attachments and other included items.

SWO required before claim submission; supplier forms/attestations alone insufficient

A Standard Written Order (SWO) must be communicated to the supplier before claim submission; adequate supporting medical record documentation is required and supplier-prepared forms or attestations alone are insufficient to establish medical necessity.

• SWO must contain member identifier, order date, item description (HCPCS code or brand/model), separately billed options/accessories with HCPCS and quantity, treating practitioner name/NPI, and signature.
• Forms are subject to corroboration with information in the member’s medical record.

Clinical documentation must support the three medical necessity components

Ensure clinical documentation supports the three medical necessity components: significant mobility limitation (impacting MRADLs), the member’s ability to safely use the device, and that the device will sufficiently improve functional mobility; the policy references DME MAC local medical policy as part of its basis.

• Document the specific MRADL impact and safety assessment.
• Document expected functional improvement attributable to the device.

Do not submit separate claims for Column II items when provided with corresponding Column I walker items

Do not submit separate claims for Column II items when provided with the corresponding Column I walker items — Column II items are included in the allowance for the primary item and should not be billed separately.

• Examples: replacement handgrip and replacement tip included with rigid or folding walkers; wheel and brake attachment replacement included where listed.