ALL of the following

• Equipment is necessary and reasonable for the treatment of an illness or injury or to improve functioning of a physical deficit.
• Education regarding use of the device has been provided with demonstrated understanding.
• A trial of the requested device has been provided with demonstrated ability to use it safely and effectively.
• Consideration that a less costly medically appropriate alternative exists and should be used when adequate (deluxe/aesthetic upgrades or items for convenience are not reasonable).

  Deluxe/aesthetic upgrades or items for convenience are not reasonable.

ALL of the following

• Equipment is necessary and reasonable to diagnose or treat a medical condition or to enable the member to perform activities of daily living.
• Documentation supports clinical need (see device-specific sections for required documentation).

  I.A.1 added in 08/25 revision.

ALL of the following

• Member/enrollee is at risk of a post-burn contracture.
• Garment plus physical and/or occupational therapy are being used with intent of preventing the need for skin grafting or contractures from hypertrophic scarring.

ALL of the following

• Not medically necessary (considered primarily a safety device).

ALL of the following

• Member/enrollee is ≥ 18 years of age with increased risk of sudden cardiac death.

• One of the following

  • Awaiting cardiac transplant.
  • Previously implanted ICD removed due to infection and awaiting re-implantation.
  • Newly indicated ICD delayed due to systemic infection or delayed due to LVEF ≤ 35% with qualifying temporal criteria (e.g., MI within past 40 days; CABG/PCI within past 90 days) or newly diagnosed potentially reversible nonischemic cardiomyopathy undergoing a trial of optimal medical therapy.
• Device is FDA-approved and used according to FDA indications.

Ongoing requests

• Initial request criteria continues to be met.
• Adherence is confirmed by device reports and attestation from the ordering provider.
• Plan of care has been updated with progression towards a definitive treatment pathway.

ALL of the following

• WCD initial authorization duration: 30 days; may be extended in 30-day increments up to a total of 90 days when ongoing criteria are met.

  Thresholds per policy

ALL of the following

• Not medically necessary due to insufficient evidence of safety/effectiveness over standard pneumatic devices.
• Devices are considered not proven safe and effective for lymphedema of the abdomen, trunk, chest, genitals, or neck and for arterial insufficiency.

  See pneumatic compression devices limitations.

ALL of the following

• Member/enrollee has diabetes and is legally blind (best corrected visual acuity of 20/200 or worse in both eyes).20/200 or worse in both eyes

ALL of the following

• Refractory psoriasis.
• Documentation supports treatment at home versus alternate sites; panel lights considered when several discrete body areas can be treated individually; cabinet-style reserved for extensive body surface area.

ALL of the following

• Not medically necessary for post-operative management, as research does not indicate improved outcomes in pain or edema management over other treatments.

ALL of the following

• Medically necessary when breast pumps are a covered benefit for the member/enrollee.

ALL of the following

• Standard bed or standard hospital bed is unable to meet positioning needs due to disability.
• Less intensive alternatives to improve safety have been tried and ruled out, with documentation (e.g., bed rails, mattress on floor, bed alarms, video/audio monitors, environmental modification, medication when physician-directed).
• Diagnosis includes one or more of: cerebral palsy, developmental delay, genetic/neurological disorder causing vertigo/disorientation/uncontrolled movement, uncontrolled seizure disorder, severe behavior disorder.
• Healthcare provider evaluation (typically OT/PT) including functional status, home evaluation, and documented caregiver education on safe use of bed enclosure.
• Name of and invoice for the bed or enclosure being requested.

ANY of the following

• Operational notes/restrictions: Enclosed beds should not be used as discipline or restraint during high agitation; use at night and short naps only; only basic beds considered medically necessary; upgrades for aesthetics or non-DME items not covered.

ALL of the following

• Documentation of therapist evaluation and an ongoing treatment plan.
• Commercial device must be unable to meet positioning needs due to height, weight, or disability.
• Other positioning devices in the home must be reviewed to ensure duplication is not present.

ALL of the following

• Require mandatory secondary review by a medical director and/or therapy advisor to determine medical necessity.

ALL of the following

• Musculoskeletal or neurologic impairment requiring traction equipment.

• ANY of the following

  • Diagnosis of TMJ dysfunction and has received treatment for TMJ condition.
  • Distortion of lower jaw and neck anatomy such that a chin halter cannot be utilized (e.g., radical neck dissection).
• Treating physician documents medical necessity for > 20 pounds of cervical traction in the home setting (if applicable).

ALL of the following

• Requests require mandatory secondary review; documentation must state why a prefabricated collar is not adequate.

ALL of the following

• Requests reviewed using relevant nationally recognized decision support tool criteria for similar codes.

ALL of the following

• Requests for AFOs and orthotic components will be reviewed using relevant nationally recognized decision support tool criteria for similar codes.

ALL of the following

• Group A: Foot condition present indicated by one of: juvenile idiopathic arthritis; pes cavus (high arch); rheumatoid arthritis; plantar fasciitis with symptoms ≥ 1 month; posterior tibial tendon dysfunction with stage I or II disease; or other listed conditions.
• Group B: Documentation that activity adjustment, anti-inflammatory medications, prefabricated orthotics, and stretching failed to improve symptoms.

ALL of the following

• Ordered immediately post-operative for procedures such as rotator cuff repair, tendon repair, or ORIF.
• Replacement with same or similar item due to normal wear and tear is medically necessary when continued need is documented.

ALL of the following

• Requests require mandatory secondary review by a medical director and/or therapy advisor.

ALL of the following

• Not medically necessary due to insufficient evidence supporting effectiveness.

ALL of the following

• Medically necessary when there is loss or absence of facial tissue due to disease, trauma, surgery, or congenital defect.

ANY of the following

• Iron poisoning for administration of deferoxamine for acute iron poisoning/overload.
• Chemotherapy for liver cancer (primary hepatocellular carcinoma or colorectal cancer with unresectable disease or patient refusal of surgery).
• With opioid drugs for intractable cancer pain.
• To administer a drug when prolonged infusion (≥8 hours) demonstrates improved efficacy or intermittent infusion episodes <8 hours meet administrative criteria (no return to physician office prior to infusion and strictly controlled infusion rate necessary).

  Device-specific criteria apply.

ALL of the following

• A — One of the following indications

  • Chemotherapy for select liver cancers as specified.
  • Intrathecal anti-spasmodic drugs for severe spasticity unresponsive to less invasive therapy with prior 6-week trial and favorable trial response.
  • Other uses when drug is reasonable/necessary and pump FDA-approved for that drug/purpose.

• B — None of the following contraindications present

  • Known allergy or hypersensitivity to the drug being used (e.g., oral baclofen, morphine).
  • Active infection.
  • Body size insufficient to support weight/bulk of device.
  • Presence of another implanted programmable device.
  • Heparin or insulin is the drug intended for administration.

ALL of the following

• Medically necessary for uninterrupted parenteral administration of medication via pump.

ALL of the following

• Medically necessary for treatment of erectile dysfunction when prescribed by a physician.

ALL of the following

• Not medically necessary — provides no clinical advantage over small-volume nebulizer (E0574) with compressor.

ALL of the following

• Medically necessary for member/enrollee with respiratory disease when an incentive spirometer is ineffective.

ALL of the following

• Medically necessary when used to monitor individuals on a home ventilator or with a tracheostomy; to determine appropriate home oxygen requirements; to wean an individual from home oxygen; or to monitor an unstable respiratory condition.
• Not medically necessary when used as a diagnostic procedure, for monitoring a stable respiratory condition, or for asthma management.

ALL of the following

• Not medically necessary — current evidence does not support effectiveness.

ALL of the following

• Mobility-related ADLs in the home cannot be met due to mobility limitation.
• Walker can be safely used by member/enrollee.
• Functional mobility deficit will be sufficiently resolved with use of a walker.
• Heavy duty walker (E0148, E0149) additionally requires member/enrollee weight > 300 pounds; E0147 considered when unable to use standard walker due to severe neurologic disorder or single-hand restriction.

ALL of the following

• Mobility limitation interferes with ability to participate in MRADLs and cannot be met with cane or walker.
• Manual wheelchair will significantly improve participation in MRADLs.
• Home provides adequate access and maneuvering space; willingness of member/enrollee or caregiver to use a wheelchair in the home.

• ANY of the following

  • Caregiver is able to assist with wheelchair use.
  • Member/enrollee is able to safely and efficiently self-propel manual wheelchair.
• Replacement medically necessary when loss/theft/irreparable damage with documentation of continued medical necessity and replacement is same/similar; or after reasonable useful lifetime ≥ 5 years or change in member status requiring different equipment.

ALL of the following

• A licensed, certified medical professional (PT/OT) involved with assessment, prescription, trials and training of equipment.
• Adequate cognitive function to safely use the seat elevating.

ALL of the following

• JACO wheelchair-mounted robotic arm is not medically necessary — insufficient evidence of safety and improved outcomes.

ALL of the following

• Medically necessary when used in lieu of a wheelchair for those who would qualify for a wheelchair except for inability to self-propel a manual wheelchair.

ALL of the following

• Item is less than 5 years old (age/date of purchase provided).
• Cost of repairs is less than cost of replacement.
• Information supports need for repairs due to normal wear and tear (not abuse/misuse).
• One month's rental for a standard manual wheelchair is allowed if a member-owned wheelchair is being repaired.
• Requests using codes K0108, K0739, or E1399 require mandatory secondary review.

ALL of the following

• Coverage for ROMTech/PortableConnect and ROMTech devices follows evidence analysis and device-specific criteria; currently ROMTech PortableConnect is considered not medically necessary due to insufficient evidence unless device-specific criteria demonstrate benefit.