Alliance Health DME Coverage & Prior Auth Update | OpenPayer
ModifiedAlliance HealthPolicy 5A-1
Durable Medical Equipment (DME) and Supplies — Coverage Criteria
Policy governing coverage, prior approval, rental/purchase rules, and documentation for durable medical equipment and related supplies for Alliance Health members under North Carolina Medicaid.
Policy Summary
PayerAlliance Health
PolicyDurable Medical Equipment (DME) and Supplies — Coverage Criteria
Policy CodePolicy 5A-1
Change TypeHCPCS, quantity, ICD-10 additions
Effective Date
Next Review Date
Key ActionSubmit prior approval requests (CMN/PA) with required clinical documentation and device specifications via NCTracks when prior approval is required.
Replaced HCPCS code E2300 with E2298 in the procedure code table to align with CMS update effective 4/1/2024.
Clarified quantity limit for HCPCS code E1028 to read: '6 per 2 years, all ages'.
Added ICD-10-CM codes M80.0B1K, M80.0B2K, M80.8B1K, and M80.8B2K to the diagnosis table for osteogenesis stimulators.
Updated instructions for completing claim form and removed outdated sample claim form images; updated invoice submission instruction for manually priced items.
Reference to 'Institutional (UB-04/837I transaction)' removed from Attachment A.
07/15/2025Most recent revision
NCState jurisdiction
1HCPCS replaced
Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.
15+
Major sections
A / CAttachment refs
Coverage Criteria for DME and Supplies
inv-01: General Coverage Criteria
Categories and basic coverage rules for DME and supplies
Category inclusion: Item falls into one of the defined categories: Inexpensive/Routinely Purchased; Capped Rental or Purchased; Equipment Requiring Frequent and Substantial Servicing; Related Supplies; Service and Repair; Individually Priced Items.
See list of categories in subsection 1.2
Capped rental rule: If clinician documents anticipated need ≤ 6 months the item must be rented; if anticipated need exceeds 6 months the item may be rented or purchased; purchase after rental initiation will be denied and ownership transfers when accrued rental payments reach Medicaid allowable purchase price.anticipated need <= 6 months
See Subsection 1.2 and Chunk 14
Frequent servicing items: Equipment requiring frequent and substantial servicing (e.g., oxygen and oxygen delivery items) are rented.
See Chunk 15
Related supplies coverage: Supplies provided for use with medical equipment owned by the beneficiary are covered when they are necessary for use with the beneficiary's equipment.
See Chunk 16
Service and repair of medical equipment owned by a beneficiary is covered over the useful life of the item per servicing and repair policies.
Refer to Subsection 5.8 and Chunk 17
Individually priced items: Items not listed in Attachment A, Section C or the DME fee schedule are reviewed and manually priced; requests must be submitted for prior approval review of medical necessity (EPSDT workflow for beneficiaries <21 via NCTracks).
See Chunk 18 for submission pathways and fee schedule reference
inv-02: Covered when ALL of the following are met
Medicaid covers DME when medically necessary and the following general and specific criteria are met.
General coverage preconditions: a) Procedure, product, or service is individualized, specific, consistent with symptoms/confirmed diagnosis and not excessive; b) can be safely furnished and no equally effective and more conservative or less costly statewide option exists; c) not primarily for convenience of beneficiary/caregiver/provider.
Chunk 25
Ordering and documentation: a) Item ordered by physician, physician assistant, or nurse practitioner; b) item medically necessary to maintain or improve medical/physical/functional level and appropriate for noninstitutional use; c) documented face-to-face encounter with ordering clinician related to the reason for DME within 6 months prior to DME initiation; d) ordering clinician reviews need at least annually.face-to-face <= 6 months; review >= annually
Chunk 26
inv-03: Hospital bed specific criteria
Hospital bed specific medical necessity criteria (each bed type has its own AND logic).
Fixed Height Hospital Bed: Fixed height bed covered when documented need for head/foot adjustments not feasible in an ordinary bed to alleviate pain, promote alignment, and prevent bedrest complications OR when special attachments that cannot be used on an ordinary bed are required.
Chunk 36
Variable Height Manual Crank Hi-Lo Bed: 1) Beneficiary meets Fixed Height Hospital Bed criteria; AND 2) Variable bed height feature is necessary for ambulation or transfer in/out of bed.
Chunk 37
Semi-Electric Hospital Bed: 1) Condition requires frequent changes in body position; AND 2) Immediate changes in head/foot position are required where delay cannot be tolerated; AND 3) Beneficiary can operate electric controls independently.
Chunk 37
inv-04: Fixed Height Hospital Bed
Fixed Height Hospital Bed covered when ANY of the following are documented:
Fixed Height Hospital Bed criteria: 1) Beneficiary's condition requires head and foot adjustments to position the body in ways not feasible in an ordinary bed to alleviate pain, promote alignment, and prevent complications of bedrest such as contractures, skin breakdown, or respiratory infections; OR 2) Beneficiary's condition requires special attachments that cannot be attached to and used on an ordinary bed.
Chunk 36
inv-05: Variable/Semi/Total Electric Beds
Variable height, semi-electric, and total electric hospital beds covered when ALL specified conditions are met (per subtype):
Variable Height Manual Crank Hi-Lo: 1) Meets Fixed Height Hospital Bed criteria; AND 2) Variable bed height feature is necessary for beneficiary to ambulate or transfer in and out of bed.
Chunk 37
Semi-Electric Hospital Bed: 1) Condition requires frequent changes in body position; AND 2) Immediate need for head/foot position changes where delay cannot be tolerated; AND 3) Beneficiary can operate electric controls independently.
Chunk 37
Total Electric Hospital Bed: 1) Meets Semi-Electric criteria; AND 2) Electric powered variable bed height feature is necessary for ambulation/transfer or to complete an activity of daily living.
Chunk 37
inv-06: Pediatric Beds
Pediatric beds (cribs, safety enclosures, pediatric specialty beds) covered when ALL of the following are met:
Pediatric bed basic criteria: 1) Physician/PA/NP order documents hospital-grade crib, safety enclosure, or specialty bed is most appropriate; AND 2) Diagnosis/condition supports need for additional features (e.g., severe spasticity, thrashing, cognitive impairment, unsafe behaviors); AND 3) Letter of medical necessity or PT/OT evaluation detailing how each feature is medically necessary and why a regular bed/rails are insufficient (therapist must not have financial relationship with supplier); AND 4) Documentation that environment supports use; AND 5) Documentation caregiver/family can safely and appropriately use equipment.
Chunks 38-39
inv-07: Group 1 Support Surfaces
Group 1 Pressure-Reducing Support Surfaces are covered when ANY of the following are present:
Group 1 coverage: a) Beneficiary is completely immobile; OR b) Beneficiary has limited mobility plus one of: impaired nutrition, fecal/urinary incontinence, altered sensory perception, compromised circulatory status, or inability to respond to pain; OR c) Any stage pressure ulcer on trunk/pelvis with one of: impaired nutrition, altered mental status, incontinence, altered sensory perception, or compromised circulatory status.
Group 1 overlays/mattresses must be rented if anticipated need <=6 months except specified purchase-only exceptions (Chunk 43)
inv-08: Group 2 Support Surfaces
Group 2 Support Surfaces initial approval requires ONE of the following conditions and documentation of a comprehensive ulcer treatment program:
Group 2 initial criteria set: a) Multiple Stage II ulcers on trunk/pelvis that have worsened or remained the same over the past month AND beneficiary has been on a comprehensive ulcer treatment program (including appropriate Group 1 surface) for at least one month; OR b) Large or multiple Stage III or IV ulcers on trunk/pelvis; OR c) Recent myocutaneous flap or skin graft for pressure ulcer on trunk/pelvis (surgery within past 60 days) and was on Group 2 or 3 immediately prior to recent discharge (within past 30 days).
Initial PA up to 6 months; renewals up to 3 months; comprehensive program elements listed in Chunk 44
inv-09: Group 3 Support Surfaces (Air-fluidized beds)
Group 3 (air-fluidized) initial approval requires ALL of the following:
Air-fluidized bed initial criteria: a) Stage III or IV pressure sore, or status post-op muscle/skin flap repair of Stage III/IV; AND b) Beneficiary is bedridden or chair bound due to severely limited mobility; AND c) Prescribed in writing after comprehensive assessment and conservative treatment tried without success (conservative elements enumerated); AND d) Conservative treatment for at least one month prior with no improvement; AND e) Trained adult caregiver available to assist with ADLs and bed management; AND f) Physician/PA/NP directs regimen and re-evaluates and recertifies monthly; AND g) All alternative equipment considered and ruled out.
Initial PA given for maximum 1 month; renewals monthly (Chunks 46-47)
Air-fluidized bed denials: Air-fluidized bed is denied if beneficiary has coexisting pulmonary disease, requires wet soaks/moist dressings not protected by occlusive covering, caregiver unavailable/unwilling, inadequate structural support or electrical system, or other contraindications.
See Chunk 47
inv-10: Manual Wheelchairs
Manual wheelchair coverage requires ALL basic criteria plus subtype-specific criteria:
Basic manual wheelchair criteria: a) Mobility limitation significantly impairs participation in one or more MRADLs; AND b) Limitation not sufficiently resolved by cane or walker; AND c) Environment accessible for wheelchair use; AND d) Use expected to significantly improve MRADLs; AND e) Beneficiary has sufficient upper extremity function to self-propel or has caregiver available to assist. Backup wheelchairs are not covered.
Chunks 50-51
Subtype: Standard Hemi: Basic criteria plus: lower seat height (17-18 inches) required due to short stature or to permit foot propulsion.
Chunk 50
Subtype: Lightweight: Basic criteria plus: beneficiary cannot self-propel in standard wheelchair; can safely self-propel lightweight wheelchair; documentation of upper extremity limitations required.
Chunk 51
inv-11: Transport and Roll-about Chairs
Transport chairs and roll-about chairs coverage:
Transport/Roll-about chairs: Adult and pediatric transport chairs and roll-about chairs are covered when medically necessary. Prior approval is required for transport chairs; roll-about chairs do not require prior approval.
Chunk 55
inv-12: Wheelchair coverage criteria
Covered when ALL of the following are met for the specified wheelchair type
Standard requirements for power wheelchair prior approval: Face-to-face in-person physician exam documented in chart with major reason a mobility exam; detailed narrative of strength, mobility, functional deficits; explanation why power wheelchair is needed vs cane/walker/manual wheelchair; onsite written environmental assessment with measurements; MSRP quote from manufacturer; other clinical records may supplement.
Standard Power Wheelchair coverage: a) Mobility limitation significantly impairs one or more MRADLs; b) limitation not sufficiently resolved by cane/walker; c) insufficient upper extremity function to self-propel an optimally-configured manual wheelchair throughout the day; d) mental and physical capability to safely operate and care for the power wheelchair; e) use reasonably expected to significantly improve MRADLs; f) environment accessible and provides adequate access and maneuvering space.
Complex Rehab Power Wheelchair additional requirements: Clinical wheelchair evaluation by PT/OT with specific training (no financial relationship with supplier) and letter of medical necessity; documentation for alternative drive controls or power seating features; MSRP quote and detailed clinical justification.
inv-13: Power Seating Systems (tilt/recline)
Power seating systems (tilt, recline, combination) are covered when ALL of the following are met
Power seating coverage: a) Requires tilt in space for proper positioning during daily activities (e.g., eating); b) significant trunk/hip musculoskeletal deformity or abnormal trunk tone necessitating tilt to maintain postural control or spinal alignment; c) unable to actively change upright seating position and at risk for loss of skin integrity; d) respiratory, digestive, or cardiac dysfunction functionally improved with tilt/recline; e) spends >= 6 hours/day in wheelchair; f) no caregiver available to perform this function manually.>= 6 hours/day
Prior approval required (Chunk 75)
inv-14: Seat/Back and Trunk/Extremity Supports
Seat/back components and trunk/extremity supports are covered when specified criteria are met
Non-standard seat height: Required seat height at least 2 inches greater or less than standard and beneficiary body dimensions justify need.>=2 inches
Prior approval required for non-standard seat height (Chunk 72)
Non-standard seat frame: Beneficiary's dimensions justify need for seat width, depth, or height changes AND changes needed to maintain or improve medical, physical, or functional level.
Prior approval required (Chunk 72)
Solid seat insert: Covered when needed to provide a flat surface in a wheelchair with a sling seat so beneficiary will be properly positioned.
Chunk 72
inv-15: Activity/Positioning Chairs and Hi Lo Bases
Activity/Positioning Chairs (including Hi Lo and Hi Lo Indoor Bases) are covered for beneficiaries ages 0-20 with prior approval when criteria below are met
Activity Chair medical necessity: Beneficiary cannot safely sit in regular/commercial chair; or needs additional support for fine motor tasks; or has decreased trunk strength/motor control; or must use arms to maintain sitting balance; or requires external support to maintain upright position and alignment; or lacks protective/righting reactions; or must be upright supported for safe/effective feeding.
All accessories must be medically justified (Chunks 79-80)
Tilt/recline accessory: Covered when beneficiary cannot maintain head control upright; requires pressure relief; requires tilt to compensate for tonal changes; or must be tilted for digestion/avoid reflux.
Chunk 80
Mobile base: Covered when medically necessary to move beneficiary safely within environment.
Chunk 80
inv-16: Patient Lifts (hydraulic/mechanical)
Hydraulic or mechanical patient lifts require prior approval and are covered when ALL criteria are met
Hydraulic lift coverage: Beneficiary's condition requires periodic movement to effect improvement or arrest/retard deterioration AND beneficiary/family cannot transfer beneficiary safely.
Powered lifts are not covered (caregiver convenience) (Chunk 83)
inv-17: Pneumatic Compression Devices
Pneumatic compression devices are covered only for refractory lymphedema or, with additional criteria, for scarring-related lymphedema
Refractory lymphedema: Covered only for treatment of refractory lymphedema involving one or more limbs; requires physician prescription and oversight, a treatment plan (pressure, frequency, duration), prior approval, and documentation that less intensive treatments were tried and inadequate. Block 24 of CMN/PA must be checked.
Chunk 84
Scarring of lymphatic channels with ulcers: When cause is scarring, covered only if significant lower extremity ulceration present; repeated standard treatment tried; and ulcers failed to heal after six months of continuous treatment.>=6 months
Chunk 85
inv-18: TENS Units
Transcutaneous Electrical Nerve Stimulation (TENS) units require prior approval and documentation
TENS coverage: For initial and renewal approval provide documentation that primary application is control/suppression of chronic pain not amenable to eliminating cause; include diagnosis, onset/duration, pain area(s), prognosis, prior treatments tried (including medications), statement of improved ADL tolerance with TENS, pain scale and body map. TENS must be rented 30-60 days prior to purchase request.30-60 days rental before purchase
Chunk 86
inv-19: Osteogenesis Stimulators
Osteogenesis stimulators require prior approval and specific radiographic/time-based criteria
Non-spinal electrical stimulator: Covered for non-union of long bone fractures defined as radiographic evidence that fracture healing has ceased for >=3 months prior to treatment; failed fusion of non-spinal joint with >=9 months since last surgery; or congenital pseudarthrosis. Requires minimum of two sets of radiographs separated by >=90 days with physician interpretation showing no healing. Stimulator for fracture <6 months or fusion <12 months is not medically necessary.>=3 months non-union; radiographs separated >=90 days
Chunk 87
Spinal indications: Covered for failed spinal fusion with >=9 months since last surgery; multilevel spinal fusion (>=3 vertebrae); or history of previously failed fusion at same site.>=9 months
Chunk 88
Ultrasonic stimulator:
inv-20: Continuous Passive Motion (knee)
CPM devices for knee only are covered for total knee replacement patients with timing limits
CPM coverage: Covered when used for beneficiaries who have received a total knee replacement; must commence within 2 days post-op and coverage limited to 3 weeks. Block 24 of CMN/PA must be checked indicating physician monitoring.Start <=2 days post-op; duration <=3 weeks
Chunk 89
inv-21: Canes, Crutches, Walkers, Gait Trainers
Canes and crutches are covered when ALL criteria are met
Canes/Crutches coverage: Beneficiary has a mobility limitation that significantly impairs participation in one or more MRADLs; beneficiary is able to safely use the cane/crutch; and the functional mobility deficit can be sufficiently resolved by use of a cane/crutch. MRADLs defined as toileting, feeding, dressing, grooming, bathing. If criteria not met, device denied.
Chunk 90
Crutch substitute (lower leg platform): Requires prior approval and is covered if beneficiary meets above criteria and cannot safely use crutches or a walker.
Chunk 90
Heavy duty ambulatory aids: Covered for beneficiaries who weigh more than 250 pounds; prior approval required and CMN/PA must include beneficiary height, weight, body measurements, requested equipment dimensions, and manufacturer's specified weight capacity.>250 pounds
Chunk 91
inv-22: Heavy Duty Canes and Crutches
Heavy duty canes and crutches coverage
Heavy duty ambulatory aids: Covered for beneficiaries who weigh more than 250 pounds; prior approval required and CMN/PA must include beneficiary height, weight, body measurements, equipment dimensions, and manufacturer's specified weight capacity.>250 pounds
Chunk 91
inv-23: Canes and Crutches (Initial coverage)
Canes and crutches are covered when ALL of the following are met
Cane/Crutch coverage criteria: a) Beneficiary has a mobility limitation that significantly impairs participation in one or more MRADLs (toileting, feeding, dressing, grooming, bathing) by preventing completion, posing heightened risk of injury/morbidity, or preventing completion within a reasonable time; b) Beneficiary able to safely use the cane/crutch; c) Functional mobility deficit can be sufficiently resolved by use of a cane/crutch.3/3
Chunk 90
inv-24: Heavy-Duty Canes and Crutches
Heavy-duty canes and crutches
Heavy-duty device requirements: Beneficiary weighs more than 250 pounds; prior approval required with CMN/PA including beneficiary height, weight, body measurements, equipment dimensions, and manufacturer's specified weight capacity.2/2
Chunk 91
inv-25: Standard Walkers
Walkers
Standard walker coverage: a) Mobility limitation significantly impairs MRADLs; b) Beneficiary able to safely use walker; c) Functional mobility deficit can be sufficiently resolved with walker. Prior approval not required for standard walkers; glides/skis require prior approval; heavy-duty walker documentation required for beneficiaries >250 lb.3/3
Chunk 92
inv-26: Gait Trainers (Pediatric)
Gait trainers (ages 0–20) with accessories
Gait trainer pediatric criteria: a) Needs moderate to maximal support for walking due to impaired balance reactions or pelvic/trunk instability or GMFCS score ≥3; b) Beneficiary able to initiate movement without caregiver assistance and there is a purposeful need for movement. PT/OT evaluation required; therapist must not be employed by DME provider.2/2
Chunk 93
inv-27: AAC Devices
Augmentative and Alternative Communication (AAC) devices
AAC device coverage criteria: a) Device determined medically necessary; b) Device is a dedicated communication device; c) Used solely by beneficiary; d) Beneficiary has a long-term severe communication impairment. Speech-generating devices, software, accessories, and repairs require prior approval with CMN/PA including physician report, physician order itemizing components, and licensed speech-language pathologist evaluation meeting credential/content requirements.4/4
Chunks 95-97
inv-28: AAC Rental Period
AAC rental and purchase policy
AAC rental-before-purchase: Devices requiring prior approval must be rented for one month before Medicaid purchases; rental fees apply to purchase price. If rental unavailable, PA for purchase may be granted with documentation of recent effective experience. Replacement of existing AAC does not require rental unless needs have changed.1 month rental
Chunk 98
inv-29: AAC Costs and Replacement
AAC cost, repairs, and replacement rules
AAC cost and replacement limits: Total cost of AAC device, software, mounting, accessories, repairs shall not exceed $9,500 per beneficiary over a two-year period; repairs limited to $500 annually (excess requires prior approval); lifetime expectancy three years. Replacement or modification allowed when beneficiary status changes, device irreparable, repairs not cost-effective after warranty, manufacturer does not cover repair, or damage/theft with report.$9,500/2 years; $500/year; lifetime 3 years
Chunk 99
inv-30: Standers (Pediatric)
Standers (ages 0–20)
Stander coverage criteria: a) Requires moderate to maximal support for standing in the environment; b) Unable to stand/ambulate due to long-term conditions and ambulation unlikely; c) Effective weight bearing cannot be achieved by other means; d) Stander has been tried and used safely; e) Environment can accommodate stander; f) Beneficiary demonstrated motivation to stand; g) Caregiver willing and able to carry out prescribed standing program. PT/OT evaluation required; CMN/PA and documentation of least expensive appropriate device and rationale for rejecting less costly options required; therapist must be independent of provider.7/7
Chunks 100-101
inv-31: Bath & Toilet Aids
Bath and toilet aids
Bath/Shower Chair or Bench: Bath/shower chairs considered medically necessary when beneficiary cannot stand for bathing; tub transfer benches when beneficiary cannot safely get into or out of tub. Heavy duty transfer bench allowed for beneficiary >=250 lb. Prior approval not required except as specified for pediatric items.
Chunks 103-105
Raised toilet seat and commode chair: Raised toilet seat medically necessary when beneficiary cannot get up/down to standard commode; commode chair for those physically incapable of using standard toilet or without bathroom access. Extra wide/heavy duty commode chairs covered for beneficiaries >=250 lb.>=250 lb for heavy duty
Chunk 104
Pediatric bath chairs, shower chairs, bath lifts, and transfer systems covered for ages 0-20 when medically necessary; pediatric bath chair prior approval required and covered when beneficiary meets any listed criteria (cannot maintain sitting, needs reclining/tilt, poor head control, cannot be safely lifted due to size/weight, requires positioning/support). Specified safety equipment does not require prior approval.
inv-32: Shower/Commode Chair (adult/pediatric where applicable)
Shower/Commode Chair: considered medically necessary when ANY of the following are met
Shower/Commode Chair criteria: a) Cannot stand for bathing in the shower; b) Cannot be safely assisted into or out of a bath tub for bathing; c) Lacks adequate balance or trunk support to sit on a tub bench for bathing; d) Lacks access to a bathtub and cannot stand for bathing in a shower.
All accessories require medical justification (Chunk 108)
inv-33: Tilt/Recline Shower/Commode Chair
Tilt/Recline Shower/Commode Chair: considered medically necessary when ANY of the following are met
Tilt/Recline Chair criteria: a) Extensive weakness, contractures, or abnormal tone requiring full body support; b) Requires total assistance for transfers and bathing; c) Cannot sit upright and must be tilted or reclined for safe positioning while bathing; d) Has medical need that requires tilted or reclined position when upright; e) Requires pressure relief at all times when sitting.
All accessories require medical justification (Chunk 109)
inv-34: Pediatric Bath/Shower Transfer System
Pediatric Bath/Shower Transfer System: considered medically necessary when ANY of the following are met
Pediatric Bath Transfer criteria: a) Requires maximal assistance to sit; b) Has extensive weakness, contractures, or abnormal tone requiring full body support; c) Requires total assistance for transfers and bathing; d) Must use a bathtub for bathing.
Letter of medical necessity from independent PT/OT required and CMN/PA with least expensive appropriate device rationale (Chunk 110)
inv-35: Pediatric Toileting Devices
Pediatric Toilet Supports, Reducer Rings, Lo-Back Support, Potty Trainer, and Toileting Systems: considered medically necessary when ALL applicable device-specific criteria are met for beneficiaries age 0 through 20 years
Pediatric Toilet Supports/Systems general: Toilet supports and toileting systems require prior approval and are covered for ages 0–20 when medically necessary; specific device criteria include toilet training status or trainability within 6 months, inability to maintain sitting balance, need for pelvic/trunk support, inability to sit without complete caregiver support, significant deficits in balance/coordination or head/trunk control, or need for toileting outside bathroom. Letter of medical necessity from independent PT/OT and CMN/PA documenting least expensive appropriate device and rationale required.age 0-20
Chunks 111-115
inv-36: General coverage structure
Policy contains device-specific coverage criteria and conditions where items are covered; many sections were updated over time to align with Medicare or clarify documentation requirements.
Policy organization: Durable Medical Equipment coverage is organized into categorical policies and updated periodically; providers should refer to attachments and the fee schedule for HCPCS codes, lifetime expectancies, quantity limits, and prior approval indicators.
See history and attachment references in Chunks 148,153,161
Once rental of an item has been initiated based on the ordering clinician's documentation that the anticipated need is six months or less, a later request to convert that item to purchase will be denied. The policy requires that accrued rental payments reach the NC Medicaid allowable purchase price before ownership transfers; providers and ordering clinicians should document anticipated need on the CMN/PA to support initial rental versus purchase decisions and avoid subsequent purchase denials.
Items supplied primarily for beneficiary or caregiver convenience, for backup/duplication at multiple locations, or provided in an inpatient setting where payment for room and board is or could be made (unless provided as part of a documented discharge plan to a residential setting) are not covered. Also excluded are items covered by another agency and items for hospice diagnoses as specified in the hospice policy (Policy 3D).
Hospital-grade cribs, safety enclosures, and pediatric specialty beds require specific clinical justification and prior approval. These items are not medically necessary when provided for caregiver convenience, behavior therapy, physical restraint, as a substitute for appropriate supervision, or when a regular bed would meet the beneficiary's needs. Prior approval documentation must include a clinician order and a therapist evaluation or letter of medical necessity describing why ordinary beds or less costly alternatives are inadequate.
HCPCS, ICD-10, and Procedure Codes
ICD-10 Codes (selected)ICD-10
S42.256K
Open fracture of unspecified part of shaft of humerus, subsequent encounter with delayed healing
S42.261K
Displaced fracture of neck of humerus, subsequent encounter with delayed healing
S42.262K
Displaced fracture of greater tuberosity of humerus, subsequent encounter with delayed healing
S42.263K
Displaced fracture of lesser tuberosity of humerus, subsequent encounter with delayed healing
S42.264K
Fracture of surgical neck of humerus, subsequent encounter with delayed healing
S42.265K
Fracture of shaft of humerus, subsequent encounter with delayed healing
S42.266K
Fracture of lower end of humerus, subsequent encounter with delayed healing
S42.271K
Fracture of olecranon of ulna, subsequent encounter with delayed healing
S42.272K
Fracture of coronoid process of ulna, subsequent encounter with delayed healing
S42.279K
Other fracture of ulna, subsequent encounter with delayed healing
1–10 of 88
1/9
ICD-10 Codes (additional)ICD-10
S42.471K
Fracture of acromion process, subsequent encounter with delayed healing
S42.472K
Fracture of glenoid process, subsequent encounter with delayed healing
S42.473K
Other specified shoulder girdle fractures, subsequent encounter with delayed healing
S42.474K
Unspecified shoulder girdle fracture, subsequent encounter with delayed healing
S42.475K
Fracture involving multiple parts of shoulder girdle, subsequent encounter with delayed healing
S42.476K
Other shoulder fractures, subsequent encounter with delayed healing
S42.481K
Fracture of unspecified part of upper arm, subsequent encounter with delayed healing
S42.482K
Fracture of head of humerus, subsequent encounter with delayed healing
S42.489K
Other specified humerus fractures, subsequent encounter with delayed healing
S42.491K
Fracture of shaft of humerus, subsequent encounter with delayed healing
1–10 of 36
1/4
Notes / Referential Guidancemixed
Note
These ICD-10-CM codes are included to support mapping to procedure and device entries in Attachment A, Section C. Use the specific code that most accurately reflects laterality, encounter type, and healing status as documented in the medical record.
Prior Authorization, Submission, and Billing Actions
Prior Authorization
Prior Authorization Required
Prior approval is required for many durable medical equipment (DME) and related supplies. Items that require prior approval are identified on the NC Medicaid Durable Medical Equipment Fee Schedule and in Attachment A, Section C of this policy. Prior approval is valid only for the period shown on the CMN/PA form; requests for extension require submission of a new CMN/PA. Providers must submit CMN/PA and supporting documentation as specified for each item. Failure to obtain required prior approval may result in claim denial or recoupment.
All hospital beds, Group 2 and Group 3 pressure-reducing support surfaces, all manual and power wheelchairs (including pediatric, oversized, and heavy-duty), many seating/accessory items, certain batteries/chargers, activity/positioning chairs, lifts, AAC devices, pneumatic compression devices, TENS units, osteogenesis stimulators, bath/shower/commode items, pediatric toileting systems and standers require prior approval as specified in this policy.
Prior approval is required for unlisted or individually priced items; submit these requests through NCTracks per Attachment D. For beneficiaries under age 21, request an EPSDT review using NCTracks.
Prior approval for capped rental items follows rental/purchase rules: if rental is initiated, a later purchase PA will be denied; allowable rental periods carry over when suppliers change.
Medical Necessity and Individually Priced Items
inv-195: Individually Priced / Unlisted Items
Medical necessity and procurement pathways for items not listed in fee schedule
Unlisted item review: Items not listed in Attachment A, Section C or in the Durable Medical Equipment fee schedule will be considered for coverage if requested by a provider or beneficiary and submitted through NCTracks for prior approval review of medical necessity; EPSDT review required for beneficiaries under 21.
Chunk 18
inv-196: Hospital bed medical necessity
Specific medical necessity requirements by hospital bed type.
Fixed Height Bed: Requires head/foot adjustments to alleviate pain/promote alignment/prevent bedrest complications OR requires special attachments not usable on ordinary bed.
Chunk 36
Rental, Purchase, and Capped Rental Rules
Item
Rule
Capped rental items; oxygen equipment
Rented. Items in 'Equipment Requiring Frequent and Substantial Servicing' (including oxygen and oxygen delivery items) are rented.
Anticipated need ≤ 6 months
Item is rented when the ordering clinician documents anticipated need is six months or less; accrued rental payments may convey ownership once they reach Medicaid allowable purchase price.
Item
Rule
Capped rental or purchased equipment
If anticipated need exceeds six months the item may be rented or purchased; however, purchase after rental initiation will be denied.
Individually priced items
Items not listed in Attachment A, Section C or the DME fee schedule are reviewed and manually priced via prior approval; EPSDT applies for beneficiaries <21 via NCTracks.
Item
Reference
Capped rental items — administrative rules
Capped rental items have restrictions on rental length; refer to Subsection 1.2 and the CMN/PA for rental periods and transfer rules when changing suppliers.
Item
Guidance
Individually priced items
Reviewed on an individual basis and manually priced; refer to Attachment A, Section C and the DME fee schedule for rates and submit prior approval requests via NCTracks for items not listed.
Item
Rental | Purchase Rule
Group 1 support surfaces
All Group 1 support surfaces must be rented when anticipated need is six months or less; certain small items (replacement pad for alternating pressure pad and dry pressure pad for standard mattress) are purchase-only. If anticipated need exceeds six months, clinician may document purchase as appropriate.
Item
Rental Rule
Group 2 support surfaces
All Group 2 items are rented; initial prior approval up to six months with renewals up to three months. Items become beneficiary property when rental payments reach the purchase price; continued coverage requires wound healing documentation.
Group 3 (air-fluidized) support surfaces
Prior approval required; initial approval is for a maximum of one month and renewable monthly; rental until healing with monthly physician recertification and caregiver/environmental requirements documented.
Item
Rental | Purchase Rule
Manual wheelchairs
Prior approval for rental of a manual wheelchair is granted for a maximum of nine months when criteria are met; payment is for only one wheelchair at a time; if anticipated long-term need documented purchase may be considered (purchase after rental initiation denied).
Batteries and chargers
Batteries necessary to operate approved power wheelchairs are covered; Group 27 batteries and battery chargers require prior approval; initial charger included with power wheelchair; replacement charger billed separately when replacement.
Item
Rental Rule
TENS unit
Prior approval required. TENS units must be rented for 30 to 60 calendar days prior to requesting purchase; clinical documentation required for initial and renewal approvals.
Item
Purchase Rule
Power wheelchair electronics
Electronic components for power wheelchairs are covered when medically necessary. Replacement electronics require prior approval and are covered when part cannot be repaired, warranty expired, replacement extends chair life, and cost is less than a new comparable wheelchair.
Item
Rental then Purchase Policy
AAC devices requiring prior approval
Any AAC device requiring prior approval must be rented for a one-month period before Medicaid will purchase it; the rental fees apply to the purchase price. If rental is unavailable, prior approval to purchase may be granted with documentation of recent effective experience. Replacement of existing AAC does not require rental unless needs have changed.
Item
Capped Rental Reference
Capped rental items — general reference
Capped rental items have rental restrictions and become beneficiary property when total rental payments reach Medicaid allowable purchase price; allowable rental period carries over to a new supplier when changing suppliers.
Item
Rental | Purchase Rule
Rental and purchased equipment (service & repair)
Service and repairs for rental equipment are provided as part of the rental arrangement at no additional charge. For purchased equipment, warranty applies; non-warranty repairs require a CMN/PA with repair estimate and prior approval when applicable.
Item
Capped Rental List Guidance
Capped rental items — transfer and termination rules
When changing suppliers, the new provider must obtain a signed CMN/PA and pick-up slip; allowable capped rental period carries over and the new supplier may receive rental payments only for the remaining balance. If rental terminated, provider may reclaim equipment within 30 calendar days; providers may not reclaim items after they become property of beneficiary.
Item
Rental Item Rule
Rental items — termination rule
If rental is terminated, providers may reclaim equipment from the beneficiary within 30 calendar days. Items rented under capped rental become beneficiary property when total rental payments reach the Medicaid allowable purchase price and may not be reclaimed thereafter.
Item
Rule Category
Various HCPCS-coded DME items
HCPCS-coded DME items have been historically moved between categories (rental, purchase, capped rental); current classification and fee-schedule flags (asterisk) indicate when prior approval is required—refer to Attachment A and the DME fee schedule.
Replacement and Lifetime Expectancy Rules
All listed DME — see Attachment A, Section C for replacements
Replacement guidanceAll listed DME items have replacement intervals and lifetime expectancies specified in Attachment A, Section C
Unlisted itemsFor items not listed, request a medical necessity review per sections 1.2, 2.2 and Attachment D
Fee schedule referenceRefer to the Durable Medical Equipment fee schedule for rates and additional details
Replacement innerspring mattress — see Attachment A Section C lifetimes
Replacement mattress guidanceReplacement innerspring mattress lifetime expectancies are specified in Attachment A Section C
Requesting replacementTo request replacement not listed, follow instructions in sections 1.2, 2.2 and Attachment D for medical necessity review
Documentation Requirements and Record Retention
Documentation Required
Document anticipated need duration and verify beneficiary eligibility (EPSDT for <21)
Clinician must document anticipated need duration (≤6 months vs >6 months) on the CMN/PA; providers must verify Medicaid eligibility at each service and request EPSDT review via NCTracks for beneficiaries under 21.
Documentation Required
Submit completed CMN/PA with supporting clinical documentation and LMN when applicable
Submit a completed Certificate of Medical Necessity/Prior Approval (CMN/PA) form with supporting clinical health records for all prior approval requests; a letter of medical necessity signed by the prescriber may be included.
Documentation Required
Include clinical justification and MSRP/supplier pricing for individually priced/oversized items
Include clinical justification and supplier pricing with PA requests for individually priced items and oversized equipment: beneficiary measurements, device dimensions, manufacturer's specified weight capacity, and a MSRP quote or supplier price.
Non-covered Items and Scenarios
Per policy, requests to purchase an item after rental has already begun will be denied. The ordering clinician must document anticipated need duration at the time of order; items anticipated for ≤ 6 months are to be rented. Providers should verify documentation on the CMN/PA because accrued rental payments — not a later purchase PA request — determine transfer of ownership.
The program does not cover equipment or supplies that are provided for convenience, intended as backups/duplicates, or furnished in inpatient settings where room and board are paid unless there is an established discharge plan to a residential setting. Items covered by other agencies or provided for hospice diagnoses per the hospice clinical policy are also excluded.
A foam overlay or mattress that lacks a waterproof cover is not considered durable and is therefore non‑covered. In addition, pediatric specialty beds and hospital‑grade cribs/safety enclosures are not covered when their use is solely for caregiver convenience, behavior management, physical restraint, or when a standard bed would meet the beneficiary's needs; such situations are explicitly listed as non‑medically necessary.
The amended policy notes that outdated references to federal laws were removed and some historical code references were end‑dated, but this section contains no newly added explicit not‑covered equipment categories beyond the exclusions already specified elsewhere in the policy.
Background and Scope
Durable Medical Equipment (DME) is equipment that is primarily and customarily used to serve a medical purpose, is generally not useful in the absence of a disability, illness, or injury, and is capable of repeated use. Supplies are healthcare items that are consumable or disposable or cannot withstand repeated use by more than one individual. Together these definitions form the scope of items governed by this policy and distinguish reusable, medically necessary equipment from non‑durable or convenience items.
Note
Key Definitions
Durable Medical Equipment definition
DefinitionDurable Medical Equipment (DME) is equipment primarily and customarily used to serve a medical purpose, not generally useful absent a disability, can withstand repeated use, and can be reusable or removable
Context of useDME must be appropriate for use in noninstitutional settings where normal life activities take place
Order requirementDME must be ordered by a physician, physician assistant, or nurse practitioner to be covered
Supplies definition
DefinitionSupplies are healthcare-related items that are consumable or disposable or cannot withstand repeated use by more than one individual and are required to address a beneficiary's medical disability, illness, or injury
Durability distinction
Policy Changes and Revision History
01/01/2006hcpcs_update
Multiple historical HCPCS code retirements and replacements recorded (e.g., E1025/E1026/E1027 end-dated and numerous K-/E- codes replaced or added).
01/01/2008hcpcs_update
Additional HCPCS updates applied including deletions (B4086, E2618, W4210) and additions (A7027–A7029, B4087–B4088, E2227–E2228, E2312–E2313) and quantity corrections in Attachment E.
07/15/2025hcpcs_and_attachment_amendment
Policy Summary
PayerAlliance Health
PolicyDurable Medical Equipment (DME) and Supplies — Coverage Criteria
Policy CodePolicy 5A-1
Change TypeHCPCS, quantity, ICD-10 additions
Effective Date
Next Review Date
Key ActionSubmit prior approval requests (CMN/PA) with required clinical documentation and device specifications via NCTracks when prior approval is required.
1) Beneficiary meets Semi-Electric criteria; AND 2) Electric variable bed height is necessary for ambulation/transfer or to complete an activity of daily living.
Chunk 37
Oversized Hospital Bed and Replacement Innerspring Mattress: 1) Documentation shows beneficiary meets medical necessity for comparable standard size equipment and demonstrates need for oversized equipment; AND 2) Beneficiary height, weight, and body measurements included on CMN/PA and meet HCPCS weight requirements; AND 3) Dimensions and manufacturer's specified weight capacity included on CMN/PA.
Chunk 37
Subtype: High-Strength Lightweight: Basic criteria plus: cannot safely self-propel standard or lightweight during frequent activities; spends >=6 hours/day in wheelchair; can safely self-propel high-strength lightweight; documentation required.>=6 hours/day
Chunk 51
Subtype: Ultra Lightweight: Basic criteria plus: routine activities cannot be performed in a lightweight wheelchair; features required for functionality; spends >=6 hours/day in wheelchair; beneficiary can safely self-propel ultra-lightweight.>=6 hours/day
Chunk 51
Heavy-duty / Extra heavy-duty: Heavy-duty: basic criteria plus beneficiary weighs >250 lbs or has severe spasticity. Extra heavy-duty: basic criteria plus weight >300 lbs. Prior approval required where specified and body measurements/manufacturer specs must be submitted.>250 lbs / >300 lbs
Chunks 52-57
Tilt-in-space feature: Prior approval required and: need for proper positioning during daily activities; significant trunk/hip deformity or abnormal trunk tone requiring tilt for postural control; inability to change upright position with risk to skin integrity; respiratory/digestive/cardiac dysfunction improved with tilt/recline; and beneficiary spends >=6 hours/day in wheelchair.>=6 hours/day
Chunk 53
Pediatric Manual Wheelchair prior approval requirements: Clinical wheelchair evaluation by PT/OT (no financial relationship), letter of medical necessity from PT/OT documenting medical need for mobility and selected pediatric manual wheelchair and accessories; documentation of environment accessibility; MSRP quote; pediatric coding requirements (width/depth <=14 inches).
Oversized/Heavy Duty prior approval requirements: Beneficiary meets weight requirements for requested equipment; beneficiary height, weight, body measurements included; dimensions and manufacturer's specified weight capacity submitted; documentation substantiates need for heavier equipment vs standard size wheelchair.
Solid seat support base: Covered when replacing a sling seat and needed to properly position beneficiary; requires prior approval.
Chunk 72
Planar or contoured back: Covered when beneficiary has a diagnosis that may result in musculoskeletal deformities altering normal alignment AND spends >2 hours/day in wheelchair.>2 hours/day
Chunk 72
Trunk/Extremity Alignment Supports: Covered when beneficiary has weakness or abnormal muscle tone resulting in significantly impaired trunk/body/extremity function OR unable to actively maintain proper trunk or extremity positioning.
Prior approval required for these items except positioning belts and safety vest (Chunk 73)
Hi-Lo feature: Covered when height adjustments are needed for medically necessary activities or to allow independent transfers.
Chunk 80
Hi Lo Indoor Base: Covered when wheelchair seating system transfers to indoor base AND either a variety of heights are needed for medically necessary activities OR at low height beneficiary can independently get in/out. Letter of medical necessity from PT/OT and CMN/PA with supporting documentation required; therapist must not have financial relationship with supplier and must document least expensive appropriate device and rationale.
Chunks 81-82
Covered if non-union documented by two radiograph sets separated by >=90 days with no healing, fracture not of skull or vertebrae, and fracture not tumor related.
>=90 days
Chunk 88
age 0-20
Chunks 105-106
Bath support requires prior approval and is medically necessary when beneficiary requires minimal to moderate assistance to maintain upright seated position, exhibits extensor thrusting, or has abnormal muscle tone.
Chunk 106
Bath lift requires prior approval and is medically necessary when beneficiary needs moderate to maximal assistance to get into/out of tub and cannot be safely lifted when wet due to size/medical condition; has balance deficit or poor head/trunk control; or is independent with bathing but cannot transfer safely into/out of tub.
Chunk 107
Shower/Commode and Tilt/Recline Chairs: Shower/commode chairs require prior approval and are medically necessary when beneficiary cannot stand for bathing, cannot be safely assisted into/out of tub, lacks adequate balance/trunk support for a tub bench, or lacks access to a tub. Tilt/recline shower/commode chairs require prior approval and are medically necessary for beneficiaries with extensive weakness/contractures/abnormal tone requiring full body support, total assistance for transfers and bathing, inability to sit upright, medical need for tilt/recline, or continuous need for pressure relief. All accessories require medical justification.
Chunks 108-109
When changing suppliers for rental items (other than oxygen), the new supplier must obtain a signed CMN/PA and a pick-up slip from the prior supplier within 30 calendar days; failure may trigger investigation and possible recoupment.
Certain items (e.g., Group 2 support surfaces) require failure of a comprehensive ulcer treatment program and documentation that less intensive options were tried before Group 2/3 or air-fluidized beds are approved.
Prior Authorization
Submit PA Requests via NCTracks
Submit all prior authorization requests and any request for coverage of unlisted DME through NCTracks unless directed otherwise. Requests submitted outside NCTracks for unlisted items may be returned or denied.
Use Attachment D instructions for submitting unlisted DME and medical supplies for adults through NCTracks.
For beneficiaries under 21, include an EPSDT review request within NCTracks.
Ensure the CMN/PA form (and any required block markings such as Block 24) is complete and included with the NCTracks submission.
Billing Rule
Claims and Prior Authorization Guidance
Providers must follow NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, and this clinical policy for claims, coding, and prior authorization. Claims and authorizations may be denied for noncompliance with billing and coding rules.
Report ICD-10-CM and PCS codes to the highest level of specificity that supports medical necessity and use the current ICD-10 edition in effect at the time of service.
Bill professional claims on CMS-1500/837P and institutional claims according to National Uniform Billing Guidelines unless directed otherwise.
Follow modifiers (NU, UE, RR) and rental billing guidance when applicable.
Documentation Required
Required Documentation and Supporting Records
Documentation must substantiate medical necessity, device selection, alternative options considered, and required measurements/quotations. The CMN/PA and supporting records are integral to successful authorization and to defend later claims.
Required documentation examples: physician orders and narrative notes (face-to-face exam for power wheelchairs), therapist clinical evaluations and letters of medical necessity (wheelchairs, gait trainers, pediatric bathing/toileting items, standers), manufacturer MSRP/quotes, beneficiary height/weight/body measurements, device dimensions and manufacturer-specified weight capacity, and evidence of trial/use (e.g., rental effectiveness documentation for AAC or TENS).
Block 24 of the CMN/PA must be checked when specified (e.g., pneumatic compression devices, continuous passive motion devices).
For pediatric devices, include documentation that the device is least expensive appropriate option and rationale when less expensive alternatives were considered and ruled out.
Denial Risk
Coding Specificity and Denial Risk
Coding mismatches, insufficient specificity, or use of an incorrect ICD-10/PCS edition can trigger denials or delays. Use the code lists in Attachment A and submit diagnosis/procedure codes that support the medical necessity indicated in the CMN/PA.
Use the policy's enumerated ICD-10 code lists where provided to support claims and prior authorizations.
Ensure diagnosis codes reported support the clinical criteria required for the requested equipment (e.g., pressure ulcer staging for Group 2/3 surfaces, non-union timing for osteogenesis stimulators).
Claims or authorizations submitted with codes not matching policy requirements may be denied.
Denial Risk
Denial Triggers and Item-Specific Risks
Reasons for denial include lack of eligibility, failure to meet coverage criteria, duplication of services, experimental or excluded services, missing or insufficient documentation, or failure to follow prescribed submission routes (e.g., NCTracks for unlisted items). Certain device-specific denial triggers are noted below.
Denied purchase after rental initiation: If rental has already been initiated on a capped rental item, a subsequent PA for purchase will be denied.
Air-fluidized beds are denied as not medically necessary if the policy's required criteria (e.g., Stage III/IV ulcer, bedridden or chair-bound status, failure of conservative treatment for at least one month, caregiver availability, monthly physician recertification) are not met.
Osteogenesis stimulators: claims will be denied if non-union radiographic timing requirements are not met (e.g., less than three months for non-spinal long bone or less than nine months since last surgery for failed fusion).
Cane/crutch and ambulatory aids: heavy-duty canes/crutches require documentation of beneficiary weight >250 lb; absence of required measurements or weight capacity documentation may lead to denial.
Pneumatic compression devices: covered only after less intensive treatments have failed and when Block 24 is checked; otherwise denial is likely.
Documentation Required
Delivery, Transfer, and Pick-Up Documentation
Delivery and pick-up documentation requirements: when changing suppliers for rental items (other than oxygen), obtain the signed CMN/PA and the prior supplier's pick-up slip within 30 calendar days. Missing pick-up slips or incomplete transfer documentation can prompt investigation and possible recoupment.
The allowable rental period on capped rental items transfers to the new supplier; the new supplier may bill only for remaining rental balance.
If the new supplier must obtain prior approval for the item, they must send the CMN/PA to the address listed on the form and obtain a new prior approval number assigned to the new supplier.
Variable Height Manual Crank Hi-Lo: Meets fixed height criteria AND variable height necessary for ambulation/transfer.
Chunk 37
Semi-Electric: Frequent position changes required AND immediate changes cannot be delayed AND beneficiary can operate controls independently.
Chunk 37
Total Electric: Meets semi-electric criteria AND electric bed height needed for ambulation/transfer or ADL completion.
Chunk 37
Oversized Bed: Meets standard size medical necessity AND beneficiary measurements meet HCPCS weight requirements AND equipment dimensions and weight capacity provided on CMN/PA.
Chunk 37
inv-197: Group 1 rental/purchase rules
Purchase vs rental rules for Group 1 surfaces:
Group 1 rental/purchase: Group 1 support surfaces must be rented when anticipated need <= 6 months, except specified replacement pads and dry pressure pads which are purchase-only; if anticipated need exceeds 6 months clinician may document purchase is appropriate.anticipated need <=6 months
Chunk 43
inv-198: Group 2 rental/ownership rules
Group 2 rental/purchase and ownership:
Group 2 rental ownership: All Group 2 items are rented and become beneficiary property only when monthly rental payments reach the purchase price. Initial prior approval up to 6 months; renewals up to 3 months; continued use covered until ulcers healed with documentation required for renewals.initial PA <=6 months; renewals <=3 months
Chunks 44-45
inv-199: Group 3 rental rules
Group 3 (air-fluidized) rental/purchase rules:
Group 3 rental/ownership: Prior approval initial for maximum 1 month (renewable monthly); documentation same for renewal; air-fluidized beds typically needed 6–12 weeks post-op; continued use covered until ulcer healed with documentation if healing stalls.initial PA <=1 month; renewals monthly
Chunk 46
inv-200: Wheelchair rental
Wheelchair rental rules:
Manual wheelchair rental: Prior approval for rental of a manual wheelchair is granted for a maximum of nine months when beneficiary meets all basic manual wheelchair coverage criteria. Only one wheelchair paid at a time.rental max 9 months
Chunks 54 and 52
inv-201: Accessory medical necessity criteria
Accessory medical necessity criteria (summary examples)
Accessory-specific coverage examples: Accessories (armrests, cushions, headrests, reclining backs, elevating leg rests, residual limb supports, footrests, solid seat bases, planar/contoured backs, trunk/extremity supports, growth kits, electronics) are covered when documentation shows medical necessity per device-specific criteria (examples include spending thresholds, deformity, tone, positioning needs). Many accessories require prior approval except positioning belts and safety vest; refer to fee schedule for prior-approval flags and exact HCPCS codes.examples include >4 hours/day or >2 hours/day where specified
Chunks 60-73
inv-202: Power Seat Elevation (age-limited)
Power seat elevation special rule
Power seat elevation (ages 0-20): Power seat elevation is covered for beneficiaries ages 0 through 20 when beneficiary cannot transfer to bed or toilet without height adjustment or requires elevation to perform MRADLs. Prior approval required.Age 0-20
Chunk 75
inv-203: Electronics replacement
Replacement electronics criteria
Electronics replacement: Replacement electronics are covered when part cannot be repaired, warranty expired, replacement significantly extends wheelchair life, and cost is less than a new comparable wheelchair. Prior approval required for most electronics.
Chunk 76
inv-204: DME medical necessity summaries
Device-specific medical necessity summarized
Canes/Crutches: See Cane/Crutch coverage criteria: significant MRADL impairment, safe use, functional resolution by device; crutch substitute requires prior approval.3/3
Chunks 90-91
Walkers: See Walker criteria: significant MRADL impairment, safe use, functional resolution with walker; glides/skis require prior approval; heavy-duty walker documentation required for >250 lb.3/3
Chunk 92
Standers (pediatric): See stander criteria: moderate to maximal support, inability to ambulate long-term, tried and safe, environment appropriate, motivation and caregiver ability; PT/OT evaluation and CMN/PA required.7/7
Chunks 100-101
Bath/Shower Chairs & Transfer Devices: Bath/shower chairs for inability to stand; tub transfer bench when cannot safely transfer into/out of tub; heavy-duty bench for >=250 lb. Prior approval generally not required except pediatric items or supports requiring PA.
Chunks 103-105
AAC devices: Dedicated device for long-term severe communication impairment, used solely by beneficiary, determined medically necessary with physician and licensed SLP documentation; speech-generating devices and related items require prior approval and one-month rental before purchase unless exceptions apply; cost and repair caps apply.$9,500/2 years; $500/year; lifetime 3 years
Chunks 95-99
inv-205: Shower/Commode Chair
Shower/Commode Chair: Is medically necessary when beneficiary cannot stand for bathing; cannot be safely assisted into/out of tub; lacks balance/trunk support for tub bench; or lacks access to tub and cannot stand in shower. Accessories require medical justification.
Chunk 108
inv-206: Tilt/Recline Shower/Commode Chair
Tilt/Recline: Medically necessary when beneficiary has extensive weakness/contractures/abnormal tone requiring full body support; requires total assistance for transfers and bathing; cannot sit upright and must be tilted/reclined; has a medical need for tilted/reclined position; or requires continuous pressure relief. Accessories require medical justification.
Chunk 109
inv-207: Pediatric Bath/Shower Transfer and Toileting Systems
Pediatric Bath Transfer: Requires maximal assistance to sit; extensive weakness/contractures/abnormal tone needing full body support; total assistance for transfers and bathing; or must use a bathtub. Letter of medical necessity from independent PT/OT and CMN/PA required; least expensive appropriate device justification required.age 0-20
Chunks 110-111
Toileting System: Toileting system covered when beneficiary cannot sit on commode without complete caregiver support; has significant deficits in balance/coordination or tone; poor head/trunk control; or will be independent with system use. Accessories require prior approval.age 0-20
Certain DME items require specific clinical documentation or testing to establish medical necessity.
Respiratory devices and other examples: Where required, device-specific clinical testing or documentation (e.g., polysomnogram for respiratory devices, radiographs for osteogenesis stimulators) must be provided to support medical necessity. Refer to respective subsections and Attachment A for exact requirements.
Chunks 153 and 148
DocumentationProvide clinical justification and manufacturer specifications when requesting replacement prior to usual life expectancy
Hospital bed mattress or side rails — replaced when evidence shows worn out or broken
Replacement conditionHospital bed mattress or side rails are replaced when evidence shows they are worn out or broken and continued use of an approved beneficiary-owned hospital bed remains medically necessary
Documentation for early replacementWhen requesting replacement before usual life expectancy, explain on CMN/PA why replacement is needed and include supporting documentation
Reference for lifetimesAttachment A, Section C lists established lifetime expectancies and quantity limits for bed components
Heavy-duty trapeze bar — prior approval required; beneficiary weight must be stated
Weight documentationThe beneficiary's weight must be stated on the CMN/PA form for heavy-duty trapeze bar requests
Medical necessityCovered when beneficiary requires the accessory to reposition in an approved hospital bed and meets specified weight requirement
Upholstery — replaced when damaged or worn beyond repair (no PA required)
Upholstery replacementReplacement upholstery is covered when damaged or worn beyond repair and replacing it will increase the lifetime of the wheelchair (no prior approval required)
Provider actionSubmit documentation that upholstery is damaged/worn beyond repair when requesting replacement under warranty or service rules
Parts coverageOther replacement parts may have different PA requirements; check Attachment A and policy subsections
Wheels, tires, casters, replacement parts — as needed when no longer functional due to wear and tear
Wear-and-tear partsWheels, tires, casters, tubes, valves, inserts, and other replacement parts are covered as needed when no longer functional due to normal wear and tear
Prior approvalThese replacement parts generally do not require prior approval unless specified in Attachment A
Condition for coverageApproved wheelchair must remain appropriate for beneficiary's function for parts to be covered
AAC lifetime expectancyLifetime expectancy for AAC devices is three (3) years
Replacement criteriaAAC may be modified or replaced if beneficiary status changes significantly, device irreparable, warranty expired and repair not cost-effective, or device lost/stolen with documentation
Repair documentationAll history of service, maintenance, and repair must accompany replacement requests; repairs over annual cap require prior approval
Durable medical equipment — replaced as needed / based on lifetime expectancy in Attachment A
Replacement ruleDurable medical equipment may be replaced when repair is no longer cost-effective and the item is out of warranty; explain early replacement on CMN/PA
Supporting documentationLoss/theft/fire/natural disaster require specific supporting documents (social worker letter, police/fire report, or appropriate authority documentation)
Attachment referenceRefer to Attachment A, Section C for lifetime expectancies and Attachment D for review process on individually priced items
HCPCS-coded DME items — see lifetime expectancy and quantity limits in Attachment D
HCPCS/Attachment D referenceHCPCS-coded DME items have lifetime expectancies and quantity limits specified in Attachment D and Attachment A, Section C; consult attachments for code-specific limits
Variation by codeReplacement intervals and quantity limits vary by HCPCS code as listed in attachments
Requesting unlisted code reviewItems not listed require prior approval via NCTracks and manual pricing per Attachment D instructions
Documentation Required
Include F2F exam, environmental assessment, MSRP quote, and clinical evaluation with PA
When applicable, include face‑to‑face exam narrative, onsite environmental assessment with measurements, MSRP quote, and a clinical wheelchair evaluation or therapist letter of necessity with the PA request.
Documentation Required
Provide measurements, device specs, CMN/PA, therapist LON, and least‑expensive justification with PA
Prior approval requests must include beneficiary measurements, device dimensions, manufacturer's capacity, completed CMN/PA, therapist letter of necessity when required, and justification that the requested device is the least expensive appropriate option.
Note
Check DME fee schedule for PA flags (asterisk)
Check the Durable Medical Equipment and Supply fee schedule to determine which items require prior approval; items requiring PA are identified by an asterisk on the fee schedule.
Documentation Required
Submit CMN/PA with device‑specific supporting documentation (measurements, evaluations, reports)
Submit CMN/PA with required supporting clinical documentation per device type (e.g., measurements and device specifications for heavy‑duty items; physician report, order, and SLP evaluation for AAC devices).
Documentation Required
Therapist LON must be from an independent PT/OT (no financial relationship with supplier)
A physical or occupational therapist providing a letter of medical necessity must not be employed by or have a financial relationship with the equipment provider; this applies to pediatric devices and activity/positioning chairs.
Billing Rule
For repairs/replacements submit detailed repair estimates and loss/theft documentation as required
For repairs and non‑warranty replacements, submit a repair estimate with a breakdown of parts and labor hours; document loss/theft/fire/natural disaster with appropriate reports or letters when requesting replacement PA.
Documentation Required
Retain original CMN/PA, prescription, delivery/pickup slips and service records
Retain the original CMN/PA form, prescription signed by the ordering clinician, full item descriptions, delivery/pickup dates and signed slips, and service/repair records for audit and billing purposes.
Documentation Required
Submit device‑specific clinical documentation with PA requests
Submit all relevant clinical documentation with PA requests as specified in device sections and attachments (e.g., polysomnogram results when required for respiratory devices).
Billing Rule
Adhere to NCTracks billing guidance and DME fee schedule for claims/documentation
Adhere to NCTracks billing guidance, Medicaid bulletins, the DME fee schedule, and NC Medicaid clinical coverage policies for documentation and claims submissions.
Documentation Required
Coding must support medical necessity; use current ICD‑10 edition and full specificity
Report ICD‑10‑CM and PCS codes to the highest level of specificity that supports medical necessity and use the current ICD‑10 edition in effect at time of service.
Documentation Required
Use the policy's ICD‑10‑CM/PCS code list (Amended Jul 15, 2025) to support PAs/claims
Use the ICD‑10‑CM and PCS codes listed in the policy (Attachment A) to support claims and prior authorizations in accordance with the amended policy effective July 15, 2025.
Documentation Required
Use the amended code list effective date when submitting documentation
When submitting documentation, use the amended code lists and amendment dates indicated in the policy (Amended Date: July 15, 2025) to ensure current coding guidance is applied.
Note
Code listing excerpt — no additional DME documentation requirements in this section
This excerpt contains the ICD‑10‑CM/PCS code listings only and does not include additional DME‑specific documentation requirements beyond those specified elsewhere in the policy.
Supplies differ from DME by being consumable/disposable or not durable for repeated use
Coverage relationSupplies provided for use with beneficiary-owned equipment are covered per policy rules
Durable Medical Equipment and Supplies — ordering clinician and medical necessity definition
Ordering and medical necessityDME and supplies must be ordered by a physician/PA/NP and be medically necessary to maintain or improve the beneficiary's medical, physical or functional level
Appropriate settingItem must be appropriate for use in noninstitutional settings where normal life activities take place
Face-to-face and review intervalsFace-to-face encounter within 6 months of initiation required; ordering clinician must review need at least annually
Pressure ulcer staging definitions
Stage INon-blanchable erythema of intact skin
Stage IIPartial-thickness skin loss involving epidermis and/or dermis
Stage III/IVStage III: full-thickness skin loss involving damage or necrosis of subcutaneous tissue; Stage IV: full-thickness tissue loss with extensive destruction possibly involving muscle or bone
MRADLs listMobility-related activities of daily living (MRADLs) are: toileting, feeding, dressing, grooming, and bathing
Use in criteriaSignificant impairment in MRADLs is used to establish need for wheelchairs and ambulatory aids
Functional definition'Significantly impaired' means inability to perform, undue time to complete, or heightened risk of injury/morbidity
Dedicated AAC device definition
Dedicated AAC deviceA dedicated AAC device is used only for communication purposes (not a standard laptop/PC unless modified to run AAC software and used solely for communication)
Coverage elementsAAC devices must be medically necessary, dedicated, used solely by beneficiary, and intended for long-term severe communication impairment
Non-covered devicesStandard computers or PDAs not modified for AAC and not used solely for communication are not covered
Gait trainer definition
Gait trainer definitionA gait trainer is a wide-based frame with four casters providing postural support for beneficiaries needing moderate to maximum support for ambulation; accessories provide additional support/control
Pediatric age noteGait trainers with accessories require prior approval and may be covered for ages 0–20 with PT/OT evaluation
Therapist independenceEvaluating PT/OT must not be employed by the equipment provider
Shower/Commode Chair definition
Shower/commode chairA shower/commode chair is a shower chair with a commode cut out usable in the shower or over a commode for toileting
Prior approvalPrior approval is required for shower/commode chairs; medical justification for accessories must be included
Medical necessity criteriaCovered when beneficiary cannot stand for bathing, cannot be safely assisted into/out of tub, lacks adequate balance/trunk support, or lacks access to tub and cannot stand in shower
Tilt/Recline Shower/Commode Chair definition
Tilt/recline shower/commode chairA tilt/recline shower/commode chair can tilt or recline to provide extensive full-body support and can be rolled into a shower or over a commode
Prior approvalPrior approval is required for tilt/recline shower/commode chairs and accessories require medical justification
IndicationsUsed for beneficiaries with extensive weakness/contractures/abnormal tone requiring full body support, inability to sit upright, need for pressure relief or total assistance
Bath Shower Transfer System definition
Bath/Shower Transfer SystemA bath shower transfer system is a multi-functional transfer system including a roll-in shower chair and bath slider used for positioning and transfers into the bath
Pediatric requirementPrior approval required for pediatric bath/shower transfer systems with PT/OT letter of medical necessity and documentation of least expensive appropriate device
Use casesUsed when beneficiary requires maximal assistance to sit, has extensive weakness/contractures, requires total assistance for transfers, or must use a bathtub
Beneficiary term definition
Beneficiary term'Beneficiary' is the term used in policy in place of 'recipient' (policy language update as of 02/01/2013)
UsageTerm appears throughout the policy to refer to the individual receiving Medicaid-covered services
No clinical changeTerminology update does not change clinical coverage criteria
Osteogenesis stimulators ICD-10-CM mapping note
Osteogenesis stimulator mapping noteExtensive ICD-10-CM mapping for osteogenesis stimulators and related fracture codes appears in Attachment A; specific codes were added in the July 15, 2025 amendment
Added codesICD-10-CM codes M80.0B1K, M80.0B2K, M80.8B1K, and M80.8B2K were added to the diagnosis table for osteogenesis stimulators (07/15/2025)
Reference for claimsUse the code mappings in Attachment A when submitting prior authorization and claims for osteogenesis stimulators
ICD-10-CM / PCS code list note
ICD-10-CM / PCS listingThe policy includes enumerated ICD-10-CM diagnosis and ICD-10-PCS procedure code pairings in Attachment A for cross-reference to coverage determinations
Extensive mappingsMultiple chunks list numerous mapped code pairs; providers should reference Attachment A for applicable codes when requesting PA or submitting claims
Amendment dateRefer to the Amended Date (July 15, 2025) noted in the policy when using the code lists
ICD-10-CM and ICD-10-PCS crosswalk entries
Crosswalk entriesAttachment A contains explicit crosswalk entries pairing ICD-10-CM diagnosis codes with example ICD-10-PCS procedure codes for use in claims and PA requests
Usage guidanceProviders should supply the applicable diagnosis/procedure codes on claims as listed when billing under Policy 5A-1
Reference locationsSee Attachment A code blocks for the specific pairings and examples
Amendments to Attachment A/C and related sections updated code tables and procedural listings; several HCPCS codes (K0898, W4117, W4118, W4733) were re-added to the procedure code table and general attachment formatting and claim form instructions were revised.
04/01/2024hcpcs_replacement_effective_date
CMS updated HCPCS resulting in replacement of code E2300 with E2298 in the procedure code table (policy amended to align with CMS effective 4/1/2024).
07/15/2025policy_amendment_material_changeLatest
Policy amended to replace HCPCS E2300 with E2298 in Attachment A Section C and to clarify a quantity limit for HCPCS E1028 as '6 per 2 years, all ages'.
Note
The policy requires clinicians to document the anticipated duration of need on the CMN/PA (with ≤ 6 months indicating rental) and mandates verification of Medicaid eligibility each time a service is rendered. Over the document’s history the documentation and eligibility checks were clarified to emphasize submission of a completed CMN/PA and supporting clinical records; EPSDT reviews for beneficiaries under 21 must be requested via NCTracks and prior approval requests for unlisted items follow the NCTracks process. Providers should retain the original CMN/PA and supporting records to substantiate eligibility and medical necessity at audit.