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ModifiedAmbetter NevadaPolicy CP.MP.107

Durable Medical Equipment and Orthotics and Prosthetics Guidelines

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Criteria and coverage guidance for durable medical equipment (DME), orthotics, and prosthetics for Ambetter Nevada members, including general requirements and equipment-specific medical necessity rules.

Policy Summary

PayerAmbetter Nevada

PolicyDurable Medical Equipment and Orthotics and Prosthetics Guidelines

Policy CodePolicy CP.MP.107

Change TypeMultiple material updates (added JACO, coding revisions, standing frame restructure)

Effective Date

Last ReviewNov 24, 2024

Next Review Date

Key ActionSubmit prior authorization and device-specific clinical documentation (including home evaluation or repair estimates) per policy for initial, replacement and repair DME requests.

SourceLink

POLICY UPDATE CHANGES

Added criteria and coding for Wheelchair-mounted Assistive Robotic Arm (JACO).

Removed neuromuscular stimulator, functional neuromuscular stimulator, and peroneal nerve stimulator; transferred to CP.MP.48 Neuromuscular Electrical Stimulation (NMES).

Reorganized and revised Standing Frame criteria including new initial and replacement request requirements and pediatric age thresholds.

Added numerous code updates and new sections (e.g., Lumbar-Sacral Orthotics (LSO); MyoPro Orthosis; microprocessor-controlled KAFO L2006).

Updated pneumatic and non-pneumatic compression device criteria and clarified devices not proven safe/effective for select anatomic areas and arterial insufficiency.

One month's rental of a standard manual wheelchair is medically necessary when a member's owned wheelchair is being repaired.

Expanded references and updated multiple CPT/HCPCS code mappings and replacements (e.g., K1032/K1033 replaced with E0678/E0679; E2300 updated to E2298).

newJACO criteria added

5 yrsWheelchair lifetime

300 lbsHeavy duty walker weight

>= $250Breast pump threshold

multipleSections updated

1 monthTemporary rental allowed

Coverage Criteria

General criteria

Durable medical equipment, orthotics, and prosthetics are medically necessary when ALL of the following are met:

General criteria: 1. Education regarding use of the device provided with demonstrated understanding; 2. A trial of the requested device with demonstrated ability to use it safely and effectively.

If a medically necessary, lesser cost item exists and will suit the member/enrollee's medical needs, a higher cost item will be denied.

Burn garments

Medically necessary with associated physical and/or occupational therapy when ALL of the following are met:

Burn garments criteria: A. Member is at risk of a post-burn contracture; B. The garment and physical and/or occupational therapies are being used with the intent of preventing the need for skin grafting or contractures from hypertrophic scarring; C. Garment is requested by the PCP and/or the treating specialist.

HCPCS A6501–A6512

Policy Summary

PayerAmbetter Nevada

PolicyDurable Medical Equipment and Orthotics and Prosthetics Guidelines

Policy CodePolicy CP.MP.107

Change TypeMultiple material updates (added JACO, coding revisions, standing frame restructure)

Effective Date

Last ReviewNov 24, 2024

Next Review Date

Key ActionSubmit prior authorization and device-specific clinical documentation (including home evaluation or repair estimates) per policy for initial, replacement and repair DME requests.

SourceLink

On This Page

Breast pumps

Breast pumps are covered when listed conditions are met:

Breast pump criteria: A. Breast/chest feeding member if it is a covered benefit in the State; B. [clinical documentation per state coverage]; C. Purchase if cost is less than $250; D. If cost is greater than $250, approve as rental up to the purchase price then convert to purchase; E. Limit one per member/enrollee.<$250 = purchase; >$250 = rental then convert to purchase

See newborn care equipment section for inclusive language and state benefit applicability.

Enclosed beds

Enclosed beds are reviewed by a medical director and/or therapy advisor and considered medically necessary when ALL of the following are met:

Enclosed bed criteria: A. A standard bed or hospital bed is unable to meet positioning needs due to disability; B. Less intensive alternatives (e.g., bed rails, mattress on floor, removal of hazards, bed alarms, monitors, environmental modification, medication, routines/behavioral interventions) were tried and ruled out with documentation; C. Medical diagnosis (e.g., cerebral palsy, developmental delay, genetic or neurologic disorder) supports need; D. Healthcare provider evaluation including specific functional status and home evaluation, and documentation of caregiver education on proper use; E. Name of and invoice for the bed or enclosure provided with request.

Only basic beds considered when criteria met; aesthetic or non-DME upgrades not covered. Prior review by medical director/therapy advisor required.

Positioning seat

Positioning seats are medically necessary when ALL of the following are met:

Positioning seat criteria: A. Commercial devices cannot meet the member's positioning needs due to height, weight, or disability; B. Existing positioning devices in the home have been reviewed to avoid duplication; C. Therapist evaluation supports need and ongoing treatment is planned.

Requests require physician or therapy advisor review; HCPCS T5001 or E1399.

Not medically necessary: ROMTech PortableConnect

ROMTech PortableConnect: Not medically necessary due to insufficient evidence in peer-reviewed literature to support safety or effectiveness over available alternatives.

HCPCS E1399 and A9900

Cervical traction

Cervical traction equipment is medically necessary when ALL of the following are met:

Cervical traction criteria: A. Appropriate use of the selected home cervical traction device has been demonstrated and was tolerated; B. One of the following exists: 1) Diagnosis of temporomandibular joint (TMJ) dysfunction with prior treatment; 2) Distortion of lower jaw/neck anatomy (e.g., radical neck dissection) preventing chin halter use; 3) Treating physician documents medical necessity for greater than 20 pounds of cervical traction in the home setting.

HCPCS E0849; requests for custom cervical collars require therapist review if prefabricated collars inadequate (L0170/L0190/L0200).

Prosthetics — initial and replacement

Upper and lower extremity prosthetics requests are reviewed when listed initial or replacement criteria are met:

Prosthetic initial criteria: A. Functional needs cannot be met with activity modification or compensatory techniques; B. Requested prosthesis is anticipated to meet functional needs; C. Clinical examination demonstrates appropriate residual limb length, stable limb volume, ability to tolerate weight of prosthesis, appropriate environmental exposures, access to specialized services, stable skin/strength/ROM, and cognitive function necessary to master prosthetic use; D. Comprehensive prosthetic rehabilitation plan including pre-prosthetic training, method of control, functional task training, home exercise program, and follow-up care schedule.

Requests reviewed by medical director/therapy advisor; HCPCS upper and lower extremity codes apply.

Prosthetic replacement criteria: A. Replacement requested because current prosthesis no longer functions properly, or physiologic/surgical changes to residual limb prevent accommodation, or irreparable wear/damage or repair cost > 60% of replacement cost, or significant change in condition resulting in poor fit/function; B. Prosthesis has been properly cared for per manufacturer's recommendations; C. Medical documentation supports continued use, motivation, appropriate functional level, replacement with same or similar prosthesis, and updated practitioner order if required.

HCPCS replacement codes listed in policy.

Infusion pumps

Infusion pumps are medically necessary when indications and conditions are met:

Ambulatory infusion pump indications: Medically necessary when used for administration of deferoxamine for acute iron poisoning; for select chemotherapy (e.g., unresectable hepatocellular carcinoma or colorectal liver metastases); with opioid drugs for intractable cancer pain; or when prolonged infusion (≥ 8 hours) provides improved clinical efficacy or strictly controlled infusion rate is necessary.≥ 8 hours when specified

HCPCS E0780, E0781.

Implantable infusion pump criteria: A. One of the specified indications met (e.g., certain liver cancer chemotherapy, intrathecal antispasmodics after failed trials with positive intrathecal trial, intrathecal opioids for intractable pain, or other drugs FDA-approved for pump use); B. No contraindications to implantation (drug allergy, active infection, insufficient body size, presence of another implanted programmable device, or intended drug is heparin/insulin).

HCPCS E0782, E0783, E0785, E0786; trial documentation and contraindication assessment required.

Oximeter monitoring

Oximeters are medically necessary when used for monitoring in specific situations and NOT medically necessary for listed non-indicated uses:

Oximeter medically necessary uses: To monitor individuals on a home ventilator or with a tracheostomy; to determine appropriate home oxygen requirements; to wean an individual from home oxygen; to monitor an unstable respiratory condition.

HCPCS E0445.

Oximeter not medically necessary uses: Oximetry when used as a diagnostic procedure, monitoring of a stable respiratory condition, asthma management, or other conditions not listed as indicated is not medically necessary.

Not medically necessary: Ultrasonic nebulizer

Ultrasonic nebulizer: Not medically necessary because it provides no clinical advantage over the use of a small-volume nebulizer and compressor.

HCPCS E0575

Walkers

Standard and heavy duty walkers are medically necessary when ALL of the following are met:

Standard walker criteria: A. Mobility-related activities of daily living (MRADLs) in the home cannot be met due to mobility limitation; B. Walker can be safely used by the member/enrollee; C. Functional mobility deficit will be sufficiently resolved with the use of a walker.

HCPCS E0130, E0135, E0141, E0143.

Heavy duty walker criteria: Meets standard walker criteria plus either: member/enrollee weighs more than 300 pounds (HCPCS E0148/E0149) OR the member is unable to use a standard walker due to a severe neurologic disorder or restricted use of one hand (HCPCS E0147).>300 pounds

Weight threshold and device-specific HCPCS apply.

Manual wheelchair

Manual wheelchairs (initial) are medically necessary when ALL of the following are met:

Manual wheelchair initial criteria: A. Mobility limitation interferes with ability to participate in MRADLs and: 1) limitation cannot be met with a cane or walker; 2) manual wheelchair will significantly improve MRADLs; 3) home provides adequate access and maneuvering space; 4) willingness by member/enrollee or caregiver to use a manual wheelchair in the home; B. One of the following: 1) caregiver able to assist with wheelchair use; 2) member able to safely and efficiently self-propel the manual wheelchair.

HCPCS E1050, E1060, E1070, etc.

Standard walker (initial)

Requests for standard walkers are considered medically necessary when meeting ALL of the following:

HCPCS E0130, E0135, E0141, E0143.

Heavy duty walker

Requests for heavy duty walkers are medically necessary when meeting the standard walker criteria AND the following conditions:

Heavy duty walker criteria: Member/enrollee weighs more than 300 pounds OR is unable to use a standard walker due to a severe neurologic disorder or other condition causing restricted use of one hand (E0147).>300 pounds

E0148/E0149 for >300 lbs; E0147 for severe neurologic/restricted hand use.

Manual wheelchair — Initial request

Initial request is medically necessary when meeting ALL of the following:

Initial manual wheelchair: A. Mobility limitation interferes with ability to participate in MRADLs and: 1) limitation cannot be met with a cane or walker; 2) manual wheelchair will significantly improve MRADLs; 3) home provides adequate access and maneuvering space; 4) willingness by member/enrollee or caregiver to use a manual wheelchair in the home; AND B. One of the following: 1) caregiver able to assist with wheelchair use; 2) member able to safely and efficiently self-propel the manual wheelchair.

HCPCS series E1050–E1100 and examples listed in policy.

Manual wheelchair — Replacement

Replacement is medically necessary when documentation supports ANY of the following groups:

Replacement reasons: Group A: Replacement necessary due to loss, theft, or irreparable damage AND documentation supports continued medical necessity AND replacement is with same or similar equipment. Group B: ALL of the following: 1) Replacement due to useful lifetime (>= 5 years) OR change in status requiring different equipment with growth features maximized; 2) Mobility limitation still interferes with MRADLs (subcriteria a–d as in initial criteria); 3) One of: caregiver assist or member able to self-propel safely.>=5 years

Useful lifetime threshold of 5 years applies; documentation required for replacement justification.

Wheelchair and other DME repairs

Repairs are medically necessary when ALL of the following are met:

Repair criteria: A. Item is less than 5 years old (age/date of purchase provided); B. Cost of repairs is less than the cost of replacement; C. Information supports need for repairs due to normal wear and tear rather than abuse/misuse or overutilization.<5 years

Physician or therapy advisor review required for repair requests using codes K0108, K0739, or E1399. One month's rental of a standard manual wheelchair is medically necessary while owned wheelchair is being repaired.

Power wheelchair — power seat elevator

Power seat elevator on is medically necessary as a component on a power wheelchair when ALL of the following are met:

Power seat elevator criteria: A. A licensed/certified medical professional (PT/OT) involved with assessment, prescription, trials and training; B. Adequate cognitive function to safely use the seat elevating feature; C. A clear functional need for the feature is indicated; D. Provision of the feature will improve functional independence for an activity (e.g., facilitating reach for ADLs/IADLs or improving transfer biomechanics and safety).

HCPCS E2298.

Rollabout chair

Rollabout chair criteria: Medically necessary when used in lieu of a wheelchair for individuals who would qualify for a wheelchair except for the ability to self-propel a manual wheelchair.

HCPCS E1031.

Selected device coverage groups

Covered when ALL of the following are met (device-specific examples from this segment):

Standing Frame (pediatric) initial request: Meets age-based criteria AND documentation supports height and weight requirements, is alert and responsive to stimuli, has no contraindications to a standing program, and caregiver trained/available/able to safely assist.See pediatric thresholds (developmental delay in ambulation and ≥18 months; documented neurologic/neuromuscular impairments and ≥1 year)

Replacement requests must meet existing initial criteria unless exception; documentation of training and size limits required.

Wheelchair-mounted Assistive Robotic Arm (JACO): Device added with specific criteria to determine medical necessity; requests to be reviewed against device-specific functional requirements and supporting evidence.N/A

New device-specific coding and criteria added; evidence currently limited.

Pneumatic/Non-pneumatic Compression Devices: Coverage limited. Devices not proven safe/effective for lymphedema of the abdomen, trunk, chest, genitals, or neck and for arterial insufficiency; non-pneumatic device criteria added and some pneumatic device codes retired or revised.Anatomic and vascular contraindication exclusions apply

Evidence reviews and CMS NCDs referenced; HCPCS E0678/E0679 noted.

Orthotics/Prosthetics Code-based coverage: New Lumbar-Sacral Orthotics (LSO) section and additional orthotic/prosthetic codes added. Coverage requires device-specific clinical criteria, fitting, and functional deficit documentation.Device-specific functional deficits and fitting requirements per policy

Codes L0450, L2006 (microprocessor-controlled KAFO) and other L-codes updated/added.

The policy lists several miscellaneous exclusions and clarifications under coverage criteria. Notably, a non-wearable external defibrillator with integrated ECG analysis (HCPCS E0617) is considered not medically necessary because it is primarily a safety device rather than a therapeutic DME. The policy also states that non-pneumatic compression devices (HCPCS E0678, E0679) lack sufficient clinical evidence of safety and effectiveness compared with standard pneumatic compression devices and are therefore not supported for coverage in many indications.

The ROMTech PortableConnect system is explicitly identified as not medically necessary. The policy states there is insufficient peer‑reviewed evidence to support clinical benefit over currently available alternatives and lists the applicable codes: E1399 and A9900.

Intrapulmonary percussive ventilation (IPV) devices (examples: Volara™, Percussionaire TRUE‑IPV®) are noted as not supported by current evidence and therefore are considered not medically necessary in this policy context. The policy associates these devices with HCPCS E1399 when billed as unlisted DME.

The policy designates whirlpool tubs (HCPCS E1310) as not medically necessary for the wound care uses described and therefore not covered under this DME policy.

The JACO wheelchair‑mounted assistive robotic arm is addressed in the policy with respect to evidence and comparative outcomes. The policy states there is insufficient clinical evidence to demonstrate that the JACO arm provides improved safety or health outcomes compared with alternative technologies; as a result, coverage is not supported without clear device‑specific evidence and criteria.

The policy clarifies limits for compression devices: devices have not been shown to be safe or effective for treatment of lymphedema affecting the abdomen, trunk, chest, genitals, or neck, and use is contraindicated for arterial insufficiency. The revised guidance updates pneumatic and non‑pneumatic device criteria and excludes coverage for devices used in these anatomic areas or vascular conditions where safety/effectiveness is not demonstrated.

The ultrasonic nebulizer (HCPCS E0575) is stated to be not medically necessary because it offers no clinical advantage over a standard small‑volume nebulizer and compressor (e.g., E0574).

The ROMTech PortableConnect device is reiterated as lacking sufficient evidence for clinical benefit and is therefore not medically necessary when billed under E1399 or A9900.

Whirlpool tubs (HCPCS E1310) appear again in the exclusions list and are explicitly considered not medically necessary for the wound care indications referenced in the policy.

Intrapulmonary percussive ventilation is addressed multiple times: the policy states that current evidence does not support the effectiveness of IPV and therefore it is considered not medically necessary when submitted under unlisted DME codes such as E1399.

Coding and HCPCS/CPT Mapping

Burn garments HCPCSHCPCSCovered

A6501	Burn garments - HCPCS
A6502	Burn garments - HCPCS
A6503	Burn garments - HCPCS
A6504	Burn garments - HCPCS
A6505	Burn garments - HCPCS
A6506	Burn garments - HCPCS
A6507	Burn garments - HCPCS
A6508	Burn garments - HCPCS
A6509	Burn garments - HCPCS
A6510	Burn garments - HCPCS

1–10 of 12

1/2

External defibrillatorHCPCSNot Covered

E0617

Non-wearable external defibrillator with integrated ECG analysis

Non-pneumatic compression devicesHCPCSNot Covered

E0678	Non-pneumatic compression device
E0679	Non-pneumatic compression device

Voice synthesizer glucometerHCPCSCovered

E2100

Blood glucose monitor with integrated voice synthesizer

Ultraviolet panel lightsHCPCSCovered

E0691	Ultraviolet panel light
E0692	Ultraviolet panel light
E0693	Ultraviolet panel light
E0694	Ultraviolet panel light

Enclosed bedsHCPCS

E0316	Enclosed bed HCPCS
E1399	Enclosed bed miscellaneous HCPCS
E0328	Enclosed bed when combined with E0316 or E1399
E0329	Enclosed bed when combined with E0316 or E1399

Positioning seatHCPCS

T5001	Positioning seat HCPCS
E1399	Positioning seat miscellaneous HCPCS

ROMTech PortableConnectHCPCSNot Covered

E1399	ROMTech PortableConnect device
A9900	ROMTech PortableConnect device

Cervical tractionHCPCS

E0849

Cervical traction equipment

Custom cervical collarsHCPCS

L0170	Cervical collar, custom molded
L0190	Cervical collar, custom molded
L0200	Cervical collar, custom molded

Spinal orthoticsHCPCS

L0700	Spinal orthotics
L0710	Spinal orthotics
L0999	Spinal orthotics
L1000	Spinal orthotics
L1001	Spinal orthotics
L1005	Spinal orthotics

Orthotic componentsHCPCS

L2570	Orthotic components
L2580	Orthotic components
L2627	Orthotic components

Custom foot orthoticsHCPCS

L3000	Custom foot orthotics
L3001	Custom foot orthotics
L3002	Custom foot orthotics
L3003	Custom foot orthotics
L3010	Custom foot orthotics
L3020	Custom foot orthotics
L3030	Custom foot orthotics
L3031	Custom foot orthotics
L3070	Custom foot orthotics

Upper extremity prostheticsHCPCS

L6000	Upper extremity prosthetics and additions
L6010	Upper extremity prosthetics and additions
L6020	Upper extremity prosthetics and additions
L6026	Upper extremity prosthetics and additions
L6050	Upper extremity prosthetics and additions
L6055	Upper extremity prosthetics and additions
L6100	Upper extremity prosthetics and additions

Breast prostheticsHCPCS

L8030	Breast prosthetics
L8035	Breast prosthetics

Ambulatory infusion pumpsHCPCS

E0780	Ambulatory infusion pump
E0781	Ambulatory infusion pump

Implantable infusion pumpsHCPCS

E0782	Implantable infusion pump
E0783	Implantable infusion pump
E0785	Implantable infusion pump
E0786	Implantable infusion pump

Parenteral pumpHCPCS

K0455

Parenteral pump for medication administration

Vacuum erection deviceHCPCS

L7900	Vacuum erection device
L7902	Vacuum erection device

Ultrasonic nebulizerHCPCSNot Covered

E0575

Ultrasonic nebulizer

IPPBHCPCS

E0500	IPPB & supplies
E0550	IPPB & supplies

OximeterHCPCS

E0445

Oximeter

Other surgical supplies HCPCSHCPCS

L8040	Other surgical supplies
L8041	Other surgical supplies
L8042	Other surgical supplies
L8043	Other surgical supplies
L8044	Other surgical supplies
L8045	Other surgical supplies
L8046	Other surgical supplies
L8047	Other surgical supplies
L8499	Other surgical supplies
L8600	Other surgical supplies

1–10 of 16

1/2

Standard walkersHCPCS

E0130	Walker, standard
E0135	Walker, standard
E0141	Walker, standard
E0143	Walker, standard

Heavy duty walkersHCPCS

E0148	Walker, heavy duty
E0149	Walker, heavy duty
E0147	Heavy duty walker with multiple braking system/variable wheel resistance

Manual wheelchair HCPCSHCPCS

E1050	Manual wheelchair HCPCS series
E1060	Manual wheelchair HCPCS series
E1070	Manual wheelchair HCPCS series
E1083	Manual wheelchair HCPCS series
E1084	Manual wheelchair HCPCS series
E1085	Manual wheelchair HCPCS series
E1086	Manual wheelchair HCPCS series
E1087	Manual wheelchair HCPCS series
E1088	Manual wheelchair HCPCS series
E1089	Manual wheelchair HCPCS series

1–10 of 14

1/2

Other surgical supplies HCPCSHCPCS

L8040
L8041
L8042
L8043
L8044
L8045
L8046
L8047
L8499
L8600

1–10 of 16

1/2

WalkersHCPCSCovered

E0130	Walker, standard
E0135	Walker, standard
E0141	Walker, standard
E0143	Walker, standard
E0147	Walker, multiple braking/variable wheel resistance
E0148	Walker, heavy duty
E0149	Walker, heavy duty

Manual wheelchair HCPCS (examples listed)HCPCSCovered

E1050
E1060
E1070
E1083
E1084
E1085
E1086
E1087
E1088
E1089

1–10 of 36

1/4

Power wheelchair / repairs / otherHCPCS

E2298	Power seat elevator on
E1399	Unlisted DME (used in document for various items/repairs)
K0108	Wheelchair repair code referenced
K0739	Wheelchair repair code referenced
E1031	Rollabout chair

Wound care equipmentHCPCSNot Covered

E1310

Whirlpool tub

Highlighted Added/Updated HCPCS CodesHCPCS

L0450	LSO code (listed in LSO additions)
L2006	Microprocessor-controlled knee-ankle-foot orthosis (KAFO)
E0678	Non-pneumatic compression device (replacement for K1032)
E0679	Non-pneumatic compression device (replacement for K1033)
E2298	Power seat elevator on power wheelchair (updated from E2300)

MyoPro Orthosis CodesHCPCS

L8701	MyoPro Orthosis - code listed under MyoPro section
L8702	MyoPro Orthosis - code listed under MyoPro section

Not Supported/Investigational CodesHCPCSNot Covered

E1399

Intrapulmonary percussive ventilation - noted as not supported by current evidence

Manual wheelchair useful lifetime — 5 years or more

Manual wheelchair useful lifetimeReasonable useful lifetime defined as five years or more for replacement consideration.

Replacement due to loss/theft/irreparable damageReplacement permitted before five years when documentation supports continued medical necessity and replacement is with same or similar equipment.

Repairs vs replacementRepairs are preferred when item is <5 years old and repair cost is less than replacement cost; otherwise replacement considered.

Breast pump purchase threshold — purchase vs rental threshold rules

Purchase thresholdBreast pumps priced less than $250 may be approved as a purchase.

Rental then convertBreast pumps with cost > $250 approved as rental up to the purchase price and then converted to purchase.

Limit per memberLimit one breast pump per member/enrollee.

Heavy duty walker weight threshold — > 300 lbs

Heavy duty walker weight thresholdMember/enrollee weight greater than 300 pounds is required for heavy duty walkers (HCPCS E0148, E0149).

Standard walker criteria prerequisiteHeavy duty walker requests must meet standard walker criteria in addition to weight threshold.

Alternative HCPCS (E0147)E0147 (multiple braking/variable wheel resistance) is considered when member cannot use a standard walker due to restricted use of one hand or severe neurologic disorder.

Useful lifetime for wheelchair replacement — >= 5 years

Useful lifetime threshold for replacement>= 5 years is considered the reasonable useful lifetime for manual wheelchair replacement.

Replacement exceptionsReplacement prior to the useful lifetime is allowed for loss, theft, or irreparable damage with documentation of continued medical necessity and replacement with same/similar equipment.

Change in statusReplacement after useful lifetime may also be approved for a change in member status requiring different equipment when growth features of current equipment have been maximized.

Weight threshold for heavy duty walker — > 300 pounds

Heavy duty walker weight threshold> 300 pounds (member/enrollee weight) required for HCPCS E0148/E0149 heavy duty walker coverage.

Standard walker criteria requiredRequest must also meet standard walker criteria: MRADLs cannot be met, safe use, and functional mobility benefit expected.

E0147 criteriaE0147 (multiple braking/variable wheel resistance) considered when member cannot use a standard walker due to severe neurologic disorder or restricted use of one hand.

Pediatric standing frame age thresholds — developmental delay and age-specific thresholds

Developmental delay thresholdPediatric standing frame initial requests: developmental delay in ambulation and ≥ 18 months of age.

Neurological/neuromuscular impairmentFor documented neurological or neuromuscular impairments, initial requests eligible at ≥ 1 year of age.

Documentation requirementsDocumentation must support height/weight requirements, alertness/responsiveness, absence of contraindications to a standing program, and caregiver trained/available to assist.

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for durable medical equipment (DME), orthotics, and prosthetics for initial requests, replacements, and specified repairs. Providers must obtain prior authorization before delivery or billing for items when noted in equipment-specific criteria or policy tables.

Prior authorization applies to initial purchases, replacements, and certain repairs (see repair codes K0108, K0739, E1399).
Replacement requests must document continued medical necessity and justification for replacement versus repair.
One month's rental for a standard manual wheelchair is considered medically necessary if an owned wheelchair is being repaired.

Denial Risk

Less-Costly Alternative Denial Risk

If a medically necessary, lower-cost alternative exists that will meet the member's clinical needs, requests for higher-cost items will be denied. Providers should document why less costly options are not appropriate when requesting higher-cost devices.

Denial may be issued when a clinically appropriate, lower-cost item is available.
Providers should include evidence of prior trials of lesser-cost devices where applicable.

Documentation Required

Repairs Review and Documentation

Repairs using specified codes require clinician review and supporting documentation. Repair requests must demonstrate the item is eligible for repair and that repair is cost-effective compared to replacement.

Repairs billed with K0108, K0739, or E1399 require review by a physician or therapy advisor.
Repair approval criteria include: item < 5 years old (provide age/date of purchase), repair cost less than replacement cost, and evidence repairs are for normal wear and tear rather than abuse or misuse.
Information on prior repair history and current condition must be supplied.

Documentation Required

Required Documentation for Bed/Enclosure and Positioning Devices

Specific documentation is required to support requests for beds/enclosures and positioning devices. Complete submissions ensure timely review and reduce denial risk.

Therapist or physician evaluation detailing functional status, home evaluation, and education provided to caregivers.
Invoice or itemized quote for the bed or enclosure being requested.
For positioning devices: therapist evaluation, demonstration that commercial devices are inadequate due to height/weight/disability, and review of existing positioning devices to avoid duplication.

Documentation Required

Replacement and Repair Documentation Requirements

Replacement and repair requests must include documentation that supports continued medical necessity, details the nature of damage, repair cost estimates, and evidence of proper care of the original device.

For prosthetic replacements: assessment of damage, repair cost estimate when applicable, evidence prosthesis was properly cared for per manufacturer guidelines, and documentation of continued functional benefit and motivation to use the device.
For wheelchair replacements: documentation of loss/theft or irreparable damage, or proof of end of reasonable useful lifetime (typically ≥5 years) and continued mobility need.
When requesting replacement due to change in condition, provide clinical evidence of change and rationale for different equipment.

Documentation Required

General Required Documentation

All DME/O&P requests must include the required supporting clinical documentation outlined in the policy. Providers are responsible for supplying device-specific information to validate approvals.

Clinical evaluations (physician and/or therapist) describing diagnosis, functional limitations, and how the device addresses MRADLs.
Home environment assessment and confirmation of adequate access/space when applicable (e.g., wheelchairs).
Orders or prescriptions and item invoices/quotes. For specialized equipment, include age, weight, cognitive and caregiver capability information as requested by device-specific criteria.

Step Therapy

Mobility Escalation Requirement

Mobility device escalation must be demonstrated: manual wheelchairs and lesser devices must be evaluated and shown insufficient before power or more complex mobility devices are approved.

Initial manual wheelchair requests require demonstration that mobility needs cannot be met with a cane or walker and that the wheelchair will significantly improve MRADLs.
Caregiver ability to assist or member ability to self-propel must be documented.
Power wheelchair criteria require therapist involvement in assessment, prescription, trials, and training; and documentation of the functional need for advanced features (e.g., seat elevator).

Note

Step/Criterion Deferral for Retired Specialized Equipment

Certain retired or specialized equipment (for example, gait trainers and standing frames) have been deferred to standard IQ criteria or retired. Requests for these items should follow the current IQ/standard criteria or will be reviewed under general DME rules.

Gait trainers and standing frame criteria have been retired and are deferred to standard IQ criteria.
Providers should verify current policy sections or IQ guidance for equipment-specific requirements before submitting requests.

Medical Necessity Details

General DME criteria

General DME medical necessity

General DME: Education regarding device use with demonstrated understanding AND a trial of the requested device with demonstrated ability to use it safely and effectively.

Applies to all DME, orthotics, and prosthetics; prior review may be required for higher-cost or not otherwise specified items.

Manual wheelchair replacement

Manual wheelchair replacement — rules including replacement interval and conditions:

Manual wheelchair replacement: Replacement allowed when: 1) due to loss, theft, or irreparable damage with documentation and replacement with same/similar equipment; OR 2) replacement after reasonable useful lifetime of five years or more, or change in status requiring different equipment with growth features maximized and continued MRADL interference.>= 5 years

Documentation required to support continued medical necessity and replacement justification.

Mobility equipment medical necessity

Walkers: Standard walker: MRADLs in the home cannot be met due to mobility limitation; walker can be safely used; functional mobility deficit will be sufficiently resolved with walker. Heavy duty walker: meets standard walker criteria plus member weight >300 lbs or inability to use standard walker due to severe neurologic disorder/restricted use of one hand.>300 pounds

HCPCS E0130–E0149

Manual wheelchair initial: Mobility limitation interfering with MRADLs not manageable with cane or walker; manual wheelchair will significantly improve MRADLs; home access adequate; willingness to use; caregiver assistance or ability to self-propel present.

HCPCS E1050 series and examples in policy.

Manual wheelchair replacement: Replacement due to loss/theft/irreparable damage with documentation and like replacement OR replacement after useful lifetime >=5 years or change in status requiring different equipment with prior growth maximized and continued MRADL interference.>=5 years

DME medical necessity examples

Examples of device-level medical necessity nodes:

Temporary manual wheelchair rental during repair: One month's rental of a standard manual wheelchair is medically necessary if a member/enrollee's owned wheelchair is being repaired.1 month

Added as temporary coverage guidance for repairs.

Microprocessor-controlled KAFO (L2006): Coverage requires clinical documentation of functional need and device-specific fitting criteria as described in the orthotics section.N/A

Code L2006 added; review per orthotics criteria.

Rental and Purchase Rules

Item	Rule
Breast pump
Less than $250 — approve as purchase; Greater than $250 — approve as rental up to purchase price then convert to purchase; Limit one per member/enrollee.

Item	Rule
Standard manual wheelchair — rental during repair
One month's rental for a standard manual wheelchair is considered medically necessary if a member/enrollee's owned wheelchair is being repaired.

Policy	Implication
Preference for lower-cost medically necessary item
If a lower-cost medically necessary item exists that will meet the member/enrollee's needs, the lower-cost item will be approved and a higher-cost item may be denied.

Item	Rule
Standard manual wheelchair — rental
Temporary rental for one month is medically necessary while a member/enrollee's owned standard manual wheelchair is being repaired.

Replacement Policies

Manual wheelchair — every 5 years or more (useful lifetime threshold)

Manual wheelchair replacement intervalManual wheelchair replacement considered every 5 years or more (useful lifetime).

Documentation for replacementReplacement requests must include documentation supporting reason for replacement (e.g., age/date of purchase, irreparable damage, or change in status).

Repair preference when <5 yearsIf wheelchair is less than 5 years old, repairs are preferred provided repair cost is less than replacement and repairs are for normal wear-and-tear.

Manual wheelchair — every 5 years or more (useful lifetime threshold duplicate)

Manual wheelchair useful lifetime (duplicate)Reasonable useful lifetime for replacement is defined as five years or more.

Replacement conditionsReplacement before useful lifetime allowed for loss/theft/irreparable damage with documentation and replacement with same/similar equipment.

Functional criteria for replacementFor replacement after useful lifetime, continued interference with MRADLs and other baseline manual wheelchair criteria must be met.

Standing frames and other DME — replacement per device-specific criteria; replacement requests must satisfy initial criteria unless exception

Device-specific replacement ruleStanding frames and other specified DME replacements are governed by device-specific policy criteria; replacement requests must meet initial request criteria unless an exception applies.

Exception for physiologic changesReplacements due to physiologic changes may be handled differently per device-specific guidance; policy reorganizations clarified replacement expectations.

Documentation requiredProvider must supply clinical documentation verifying device-specific criteria (age, diagnosis, functional need, caregiver capability) for replacement approvals.

Documentation Requirements

Documentation Required

Enclosed bed requests — supply home evaluation, functional status, caregiver education, and invoice

For enclosed bed requests include a home evaluation and documentation of functional status, evidence that caregivers received education on proper use, and the name and invoice for the bed or enclosure being requested.

Home evaluation and functional status documented by the evaluator.
Caregiver education documentation specific to bed enclosure safety and use.
Submit the bed/enclosure name and invoice with the request.

Documentation Required

Prosthetic replacement — damage assessment, repair‑cost estimate, and care documentation required

Prosthetic replacement submissions must include a damage assessment, repair cost estimate showing repair >60% of replacement when applicable, and documentation that the prosthesis was properly cared for per manufacturer guidance.

Provide evidence of irreparable damage or repair cost comparison (>60% threshold).
Include documentation of adherence to manufacturer's care recommendations.

Documentation Required

Provide purchase date, continued‑need documentation, and repair vs replacement justification

To support approvals for replacements and repairs include the age/date of purchase, documentation of continued medical necessity for replacements, and justification why repair rather than replacement is appropriate (cost comparison and evidence of normal wear).

Age/date of purchase to verify repair eligibility (<5 years) or replacement useful lifetime (≥5 years).
Medical documentation supporting ongoing need for replacement.
Repair vs replacement cost justification showing repair is less costly when applicable.

Documentation Required

Supply clinical documentation verifying device‑specific age/diagnosis/function/caregiver criteria

Providers must supply clinical documentation verifying device‑specific eligibility criteria — including age or pediatric thresholds, diagnosis, functional need, and caregiver capability — for devices such as standing frames and other specialized equipment.

For pediatric standing frames show age/thresholds, height/weight compliance, alertness/no contraindications, and caregiver training/availability.
Document diagnosis and functional deficits tied to the requested device's criteria.

Not Covered Items and Investigational Uses

Summary background: This DME, orthotics, and prosthetics policy defines which items are covered with criteria and which are excluded. Key examples of items identified as not covered or not medically necessary include a non‑wearable external defibrillator (E0617), non‑pneumatic compression devices (E0678, E0679), the ROMTech PortableConnect (E1399, A9900), ultrasonic nebulizers (E0575), intrapulmonary percussive ventilation (E1399), the JACO wheelchair‑mounted robotic arm (E1399 as billed) pending sufficient evidence, and whirlpool tubs (E1310). The policy revisions also document updated device‑specific sections and note the evidence reviews and citations considered during revision.

Not covered grouping (duplicate entries consolidated): the document lists the same set of excluded or not‑medically‑necessary items across sections for clarity. These include E0617 (non‑wearable external defibrillator), E0678/E0679 (non‑pneumatic compression devices), E1399/A9900 (ROMTech PortableConnect), E0575 (ultrasonic nebulizer), E1399 (IPPV/IPV devices), E1310 (whirlpool tub), and the JACO robotic arm when billed to unlisted codes without supportive evidence.

The policy repeats the exclusions in multiple sections to ensure billing and clinical staff recognize these are established non‑covered items. Examples reiterated include E0617, E0678/E0679, E1399/A9900, E0575, E1310, and IPV devices under E1399.

Duplicate exclusion groupings in the not‑covered list serve as cross‑references to the device‑specific sections. Clinicians should note the coding examples provided for each excluded device when submitting claims or prior authorization requests.

Administrative note: several non‑covered items are repeatedly listed to align with code tables and device sections. Operationally, these items should be treated as ineligible for coverage absent new, robust evidence or specific contractual provisions.

Whirlpool tubs (HCPCS E1310) are listed under the not‑covered/wound care section and are considered not medically necessary for the indications described in this policy.

The policy identifies the JACO wheelchair‑mounted robotic arm as an item for which available clinical evidence is insufficient to support coverage for safety or improved outcomes versus other assistive technologies. When billed under unlisted codes (e.g., E1399), the device does not meet the policy's coverage criteria without stronger evidence.

Intrapulmonary percussive ventilation (IPV) and certain pneumatic compression device uses are specifically excluded. The policy states IPV lacks supportive evidence and is therefore not medically necessary (commonly billed under E1399), and some pneumatic/non‑pneumatic compression device applications (including treatment of specified anatomic areas and arterial insufficiency) are not considered proven safe or effective.

Definitions

DME — definition of Durable Medical Equipment

Durable Medical Equipment (DME)Equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, appropriate for home use, and not generally useful in absence of illness or injury.

Durable vs expendableDurable items are those that can be rented due to repeatable use; expendable supplies (e.g., incontinence pads, catheters) are not considered durable.

Home use suitabilityDME is appropriate for use in the member/enrollee's home setting when prescribed by a physician and necessary for treatment of an illness or injury.

Orthotic — definition of orthotic devices

Orthotic definitionOrthotic devices are rigid and semi-rigid devices used to support a weak or deformed body part or to restrict or eliminate motion in a diseased or injured body part.

ExamplesOrthotics include braces and other support devices; some durable items may fall into orthotics/prosthetics coverage categories.

Durability noteAlthough some orthotics are durable, coverage category may vary and documentation may be required to determine appropriateness.

Prosthetic — definition of prosthetic devices

Prosthetic definitionProsthetic devices are custom-made artificial limbs or assistive devices that replace a body part or function due to trauma, vascular disease, diabetes, cancer, or congenital disorders.

Coverage considerationsProsthetic requests are reviewed for functional need, residual limb characteristics, ability to tolerate weight, and comprehensive rehabilitation plan.

Replacement documentationReplacement prosthetic requests require documentation of irreparable damage or repair cost >60% of replacement and evidence of proper care.

Member/Enrollee's Home — definition of member's home

Member/Enrollee's Home definitionA dwelling, apartment, relative's home, home for the aged, or other institution unless the institution meets hospital or skilled nursing facility definitions; permanent admission to SNF/hospice makes that facility the member's home.

Impact on rental/purchasePlace-of-home status affects rental and purchase rules for DME and whether an institution is considered the member's home.

Documentation implicationsDetermination may require facility classification based on services provided (e.g., inpatient skilled nursing care).

Durable / Medical Equipment — distinction and definition details

Durable vs Medical Equipment distinctionDurable items withstand repeated use and are typically rent-type items; medical equipment is primarily for medical purposes and not generally useful absent illness or injury.

Coverage category noteSome durable items may fall into other coverage categories (e.g., supplies, orthotics, prosthetics) and require documentation to determine classification.

Expendable supplies exclusionExpendable medical supplies (e.g., ace bandages, elastic stockings) are not considered durable equipment.

JACO — Wheelchair-mounted Assistive Robotic Arm (definition)

JACO definitionWheelchair-mounted Assistive Robotic Arm (JACO) — a robotic arm mounted to a wheelchair; policy notes insufficient clinical evidence for improved outcomes in some contexts and adds device-specific criteria.

HCPCS codingDocument references JACO typically represented with unlisted code E1399 when used for this item.

Policy actionJACO criteria and coding were added to the policy; requests will be reviewed against device-specific functional requirements.

LSO — Lumbar-Sacral Orthotics (LSO) newly added orthotic category

LSO definitionLumbar-Sacral Orthotics (LSO) — a newly added orthotic category in the policy with multiple HCPCS L-codes enumerated for coverage review.

Included codesPolicy lists numerous LSO codes (e.g., L0450, L0452, L0454 ... L1005) to define the category and facilitate claims review.

Clinical criteriaLSO coverage is governed by the orthotics section criteria and device-specific fitting and functional requirements.

Background

Background: Durable medical equipment (DME) includes reusable medical devices intended for home use; orthotics support or restrict body parts; prosthetics replace a body part or function. The policy requires education and a trial demonstrating safe and effective use prior to coverage decisions, and it provides device‑specific criteria and exclusions for common DME categories.

Revision History

2021-08-21criteria_revision

Standing Frame criteria reorganized; initial and replacement requests revised with pediatric age thresholds and documentation requirements for height/weight, alertness, and contraindications to standing program.

2021-07-21additionLatest

Added device-specific criteria and coding for Wheelchair-mounted Assistive Robotic Arm (JACO) and removed neuromuscular stimulator items (transferred to CP.MP.48); revised pneumatic compression device guidance and other references updated.

Documentation and prior authorization requirements apply.