CurrentAnthemPolicy N/A

Clinical Utilization Management Criteria — Durable Medical Equipment (DME)

This document lists Anthem's Clinical Utilization Management (UM) Criteria adopted for Medicaid populations served (Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect), including several DME-related criteria. It affects providers requesting authorization for covered services and durable medical equipment for Indiana Medicaid members.

Policy Summary

PayerAnthem

PolicyClinical Utilization Management Criteria — Durable Medical Equipment (DME)

Policy CodePolicy N/A

Change TypeNo material change noted

Effective Date

Next Review Date

Key ActionSubmit documentation demonstrating the item meets the applicable Clinical UM Criteria and follow your group administrator or Anthem network representative for the submission process.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

IndianaTarget Medicaid state

CG-DME-10, CG-DME-13, CG-DME-22, CG-DME-26, CG-DME-47DME-related criteria ids

DME.00025DME-specific policy id

multipleClinical UM items

Coverage Determination & Criteria

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General Coverage Determination

Covered when ALL of the following are met:

General medical necessity framework: Requests must meet the adopted Clinical UM Criteria (for example the listed CG-DME and DME identifiers) and the Anthem Medicaid Clinical UM Guideline hierarchy for Indiana; determinations are made case-by-case and if the request does not meet established criteria it will be referred to the licensed physician reviewer for Indiana.

Non-customized national clinical guidelines (MCG) are the primary source of UM criteria; see individual criteria documents for item-level requirements.

This document does not list specific clinical exclusions for Durable Medical Equipment. Instead, coverage determinations follow the Anthem Clinical Utilization Management (UM) Guideline hierarchy for Indiana, which uses non-customized national clinical guidelines (MCG) as the primary source. Requests are evaluated on a case-by-case basis against the adopted Clinical UM Criteria and the Medicaid Clinical UM Guideline hierarchy.

Requests that do not meet the adopted Clinical UM Criteria or the Medicaid Clinical UM Guideline hierarchy are referred to an Indiana licensed physician reviewer with appropriate clinical expertise. After physician review, nonconforming requests may be determined not medically necessary and denied.

Adopted Criteria & Identifiers

Adopted DME-related Criteria Identifiersmixed

CG-DME-10	Durable Medical Equipment
CG-DME-13	Lower Limb Prosthesis
CG-DME-22	Ankle-Foot & Knee-Ankle-Foot Orthoses
CG-DME-26	Back-Up Ventilators in the Home Setting
CG-DME-47	Noninvasive Home Ventilator Therapy for Respiratory
DME.00025	Self-Operated Spinal Unloading Devices

Other Clinical UM Criteria Identifiers Mentionedmixed

CG-ANC-04	Ambulance Services: Air and Water
CG-ANC-07	Inpatient Interfacility Transfers
CG-DME-48	Vacuum Assisted Wound Therapy in the Outpatient Setting
CG-MED-39	Bone Mineral Density Testing Measurement

What Providers Must Do

Prior Authorization

Prior Authorization Governed by Adopted Clinical UM Criteria

Prior authorization and coverage decisions are governed by the health plan’s adopted Clinical Utilization Management (UM) Criteria, including applicable Durable Medical Equipment (DME) guidelines. Non-customized national clinical guidelines (MCG) remain the primary source. Requests that do not meet the established criteria will be referred to a licensed physician reviewer with appropriate clinical expertise for final determination.

Adopted Medical Policies and Clinical UM Guidelines are publicly available on the Medical Policy and Clinical UM Guideline subsidiary website.
Non-customized national clinical guidelines (MCG) are the primary UM source.

Note

Follow Group Authorization and Claims Processes

Providers contracted to serve Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect through an ACO, PMG, or IPA must follow their group’s authorization, covered benefits, and claims submission processes. For group-specific questions, contact your group administrator or Anthem network representative.

Includes but is not limited to authorization, covered benefits and services, and claims submittal.
Contact your group administrator or Anthem network representative with questions.

Denial Risk

Noncompliant Requests May Be Denied

If a request does not meet the established Clinical UM Criteria for Indiana members, it may be denied after referral to and review by a licensed physician reviewer with the appropriate clinical expertise. Providers should ensure documentation supports medical necessity per the applicable criteria to reduce risk of denial.

Denials may occur for noncompliant requests for Indiana members.
Ensure documentation aligns with the Clinical UM Criteria to support medical necessity.

Policy Background

Anthem adopts non-customized national clinical guidelines (MCG) as the primary source for its Clinical UM Criteria. The adopted criteria list and MCG guidance form the basis for medical necessity determinations for Indiana Medicaid (Hoosier Healthwise, Healthy Indiana Plan, and Hoosier Care Connect) members, with each request assessed per the Medicaid Clinical UM Guideline hierarchy.

DME Medical Necessity Framework

Coverage for DME items is governed by the applicable adopted Clinical UM Criteria identifier; examples include the DME-related identifiers listed below. Specific medical necessity requirements are contained within each referenced criteria document.

Reference-based determination: Provider must demonstrate the requested DME item meets the specific adopted Clinical UM Criteria identifier applicable to the item (examples: CG-DME-10, CG-DME-13, CG-DME-22, CG-DME-26, CG-DME-47, DME.00025) and any applicable MCG guideline requirements; absent meeting the criteria, the request is subject to referral to a physician reviewer or denial.

See the individual Clinical UM Criteria documents for item-level indications, documentation requirements, place of service and rental/purchase/replacement rules.

Rental vs Purchase & Related Rules

Summary	Action / Where to find rules
This summary references the adopted DME-related Clinical UM Criteria in the listing (for example, CG-DME-10, CG-DME-13, CG-DME-22, CG-DME-26, CG-DME-47, and DME.00025) but does not specify item-level rental versus purchase rules within this document.	Refer to each individual adopted DME policy or Clinical UM Criteria document for specific rental vs. purchase guidance, including item-level billing, rental duration, purchase thresholds, and replacement rules; the full list of adopted Clinical UM Criteria and Medical Policies is available on Anthem's Medical Policy and Clinical UM Guideline website.

Replacement Rules

Replacement — key facts

Replacement intervals specified in this documentNot specified — replacement intervals are expected to be described in the individual DME policy/criteria documents.

Where to find item-level replacement rulesRefer to each referenced Clinical UM Criteria or DME policy (e.g., CG-DME-10, CG-DME-13, DME.00025) for replacement and lifespan guidance.

Determination process for replacement requestsReplacement requests must meet the adopted Clinical UM Criteria and will be reviewed case-by-case under the Indiana Medicaid Clinical UM Guideline hierarchy; nonconforming requests are referred to an Indiana licensed physician reviewer.

Documentation required for replacementSubmit documentation demonstrating the item meets the applicable Clinical UM Criteria; follow group-specific authorization and claims processes as applicable.

Place to access full criteria and replacement rulesThe list of adopted Medical Policies and Clinical UM Guidelines is publicly available on the Medical Policy and Clinical UM Guideline subsidiary website.

Required Documentation for Requests

Documentation Required

Provide criteria-based documentation and contact group/admin for submission

Submit documentation that demonstrates the requested DME item meets the applicable adopted Clinical UM Criteria; for the submission process, contact your group administrator or Anthem network representative.

Documentation must support that the item meets the specific Clinical UM Criteria identifier referenced (e.g., CG-DME-10, DME.00025).

Items Not Covered

This listing does not identify any Durable Medical Equipment items that are categorically excluded from coverage. Instead, coverage decisions for DME are made by applying the adopted Clinical UM Criteria and the Medicaid Clinical UM Guideline hierarchy; when requests fall outside those criteria they will be referred for physician review and may be denied as not medically necessary.