Arizona Complete Health DME O&P Coverage Update

Device- and Condition-Specific Medical Necessity Rules

General DME/Orthotics/Prosthetics Medical Necessity

Covered when ALL of the following general criteria are met:

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.

Burn Garments

Medically necessary with associated therapy when BOTH criteria are met:

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.

Non-wearable External Defibrillator with Integrated ECG Analysis (E0617)

Coverage stance:

ALL of the following

Not medically necessary (considered primarily a safety device).

Wearable Cardioverter Defibrillator (WCD) - initial and ongoing requests

Initial requests: considered medically necessary for 30 days when ALL of the following are met:

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.

Non-pneumatic Compression Devices (E0678-E0681)

Coverage stance:

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.

Blood Glucose Monitor with Integrated Voice Synthesizer (E2100)

Medically necessary when ALL of the following are met:

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

Ultraviolet Panel Lights (E0691-E0694)

Medically necessary when BOTH criteria are met:

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.

Cold Pad Pump (E0236)

Coverage stance:

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.

Breast Pumps (E0604)

Coverage stance:

ALL of the following

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

Enclosed Beds (E0316, E1399, E0328/E0329 combinations)

Medically necessary when ALL of the following are met and require mandatory secondary review by a medical director and/or therapy advisor:

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.

Positioning Seat (T5001, E1399)

Medically necessary when ALL of the following are met and require mandatory secondary review:

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.

ROMTech / Not otherwise specified (E0240, T2028, T2029, K0108, K0739, E1399)

Requests for miscellaneous supplies or NOS codes:

ALL of the following

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

Cervical Traction Equipment (E0849)

Medically necessary when ALL of the following are met:

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).

Custom Molded Cervical Collar (L0170, L0190, L0200)

Coverage stance:

ALL of the following

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

Spinal Orthotics

Coverage stance:

ALL of the following

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

Ankle-Foot Orthotics (AFO) and other orthotics

Coverage stance:

ALL of the following

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

Foot Orthotics, Custom (L3000-L3080)

Medically necessary when BOTH group A and B criteria are met:

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.

Shoulder/Elbow/Wrist/Hand/Finger Orthotics

Medically necessary when ordered immediately post-operative for specified orthopedic surgeries or for replacement due to normal wear and tear when still needed.

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.

Lower Extremity Prosthetics

Coverage stance:

ALL of the following

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

Myoelectric Rehabilitation Systems (E0738, E0739)

Coverage stance:

ALL of the following

Not medically necessary due to insufficient evidence supporting effectiveness.

Facial Prosthetics (L8040-L8499 range)

Coverage stance:

ALL of the following

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

Ambulatory Infusion Pumps (E0780, E0781)

Medically necessary when used for one of the listed indications:

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.

Implantable Infusion Pumps (E0782, E0783, E0785, E0786)

Medically necessary when BOTH A and B conditions are met:

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).

Parenteral Pump for Medication Administration (K0455)

Coverage stance:

ALL of the following

Medically necessary for uninterrupted parenteral administration of medication via pump.

Vacuum Erection Device (L7900, L7902)

Coverage stance:

ALL of the following

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

Nebulizer, Ultrasonic (E0575)

Coverage stance:

ALL of the following

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

IPPB & Supplies (E0500, E0550)

Coverage stance:

ALL of the following

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

Oximeter (E0445)

Medically necessary when ALL of the following are met; not medically necessary for listed non-indicated uses:

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.

Intrapulmonary Percussive Ventilation Devices (IPV) (E1399)

Coverage stance:

ALL of the following

Not medically necessary — current evidence does not support effectiveness.

Standard and Heavy Duty Walkers (E0130-E0149 range)

Standard walker: medically necessary when ALL criteria met; heavy duty variants require additional weight or functional limitations:

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.

Manual Wheelchair

Initial requests medically necessary when ALL of the following are met; replacement rules provided.

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.

Power seat elevator on power wheelchair (E2298)

Medically necessary as a component when ALL of the following are met:

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.

Wheelchair-mounted Robotic Arm (JACO)

Coverage stance:

ALL of the following

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

Rollabout Chair (E1031)

Coverage stance:

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.

Wheelchair and other DME Repairs (K0108, K0739, E1399)

Medically necessary when ALL of the following are met:

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.

ROMTech / PortableConnect (telerehabilitation) and ROMTech device

New device coverage contingent on device-specific evidence and criteria:

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.

Relevant HCPCS / L-code Groups and Examples

Covered / Medically Necessary HCPCS / L-codes (examples listed in this part)HCPCSCovered

A6501	Burn garment - example code listed under burn garments
A6513	Burn garment (example end of listed A65xx codes)
K0606	Wearable cardioverter defibrillator (WCD) — covered conditionally
E2100	Blood glucose monitor with integrated voice synthesizer — covered for legally blind diabetics
E0691	UV panel light — covered for refractory psoriasis when criteria met
E0604	Breast pump — covered when benefit applies
E0316	Enclosed bed components — covered when criteria met
E1399	Miscellaneous DME — used for several items, often requiring secondary review
T5001	Positioning seat HCPCS example
E0849	Cervical traction equipment

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Not Medically Necessary / Insufficient EvidenceHCPCSNot Covered

E0617	Non-wearable external defibrillator with integrated ECG analysis — not medically necessary
E0678	Non-pneumatic compression device — not medically necessary
E0679	Non-pneumatic compression device
E0680	Non-pneumatic compression device
E0681	Non-pneumatic compression device
E0236	Cold pad pump — not medically necessary for post-operative management
E0738	Myoelectric rehabilitation system — not medically necessary
E0739	Myoelectric rehabilitation system — not medically necessary
E0575	Ultrasonic nebulizer — not medically necessary
E1399	Used in context of not proven/insufficient evidence items such as IPV or robotic arm

Added HCPCS codes (examples listed in revisions)HCPCS

A6502	Burn garment code (added)
A6503	Burn garment code (added)
A6504	Burn garment code (added)
A6505	Burn garment code (added)
A6506	Burn garment code (added)
A6508	Burn garment code (added)
A6509	Burn garment code (added)
A6510	Burn garment code (added)
A6512	Burn garment code (added)
A6513	Burn garment code (added)

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Added L-codes and orthotics/prosthetics codes (examples)HCPCS

L0450	Lumbar-Sacral Orthotic (LSO) series (added)
L0469	LSO related code (added)
L0621	LSO related code (added)
L1933	Ankle-foot orthosis (AFO) code (added)
L1952	AFO code (added)
L6028	Upper extremity prosthetics (added)
L6029	Upper extremity prosthetics (added)
L6031	Upper extremity prosthetics (added)
L6032	Upper extremity prosthetics (added)
L6033	Upper extremity prosthetics (added)

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Removed / moved codes (examples)HCPCS

E0616	Cardiac event monitor — criteria moved to CP.MP.243
E0465	Invasive home ventilator — moved to CP.MP.184
E0455	Oxygen tent — removed
L8701	MyoPro Orthosis - removed and replaced by E0738/E0739 in Myoelectric Rehabilitation Systems section
L8702	MyoPro Orthosis - removed
E1091	Deleted code
K0009	Deleted code

Prior Authorization, Documentation & Billing Alerts

Prior Authorization

Mandatory secondary review for specified items

All requests for the following categories require mandatory secondary review by a medical director and/or therapy advisor prior to approval: enclosed beds (E0316, E1399, E0328/E0329 when combined), positioning seats (T5001, E1399), custom molded cervical collars (L0170 and related L-codes), HKAFOs (L2050), ROMTech/NOS supplies and miscellaneous repair codes (K0108, K0739, E1399), and many prosthetics/replacements and repairs. Include the specific HCPCS/L-codes listed in the policy when routing for secondary review.

Enclosed beds: E0316, E1399 (± E0328/E0329)
Positioning seats: T5001, E1399
Custom molded cervical collars: L0170, L0190, L0200
HKAFOs: L2050 (and other HKAFO codes)
ROMTech / NOS / repair-related codes: E0240, T2028, T2029, K0108, K0739, E1399
Upper and lower extremity prosthetics and many replacements require secondary review

Clinical & Policy Context

Durable Medical Equipment (DME) is equipment that can withstand repeated use, is primarily and customarily used for a medical purpose, is appropriate for home use, and is generally not useful to a person in the absence of an illness or injury. Orthotics are rigid or semi‑rigid devices used to support a weak or deformed body part or to restrict or eliminate motion of an injured or diseased body part. Prosthetics are custom artificial limbs or assistive devices that replace a missing body part or function due to trauma, disease, congenital defect, or other condition (e.g., vascular disease, diabetes, cancer).

This policy requires that DME, orthotics, and prosthetics be prescribed by a physician and meet the plan's medical necessity rules: the item must be necessary and reasonable to treat an illness or injury or to improve functioning of a physical deficit, and documentation must demonstrate clinical need. The policy explicitly operationalized this standard by adding I.A.1 that states “Equipment is necessary and reasonable…” and includes accompanying notes about reasonableness and cost‑effectiveness.

In applying medical necessity, the policy emphasizes trials, education, and consideration of less costly medically appropriate alternatives: caregivers and/or members must receive education with demonstrated understanding, a trial of the requested device with demonstrated safe and effective use must be documented, and deluxe or aesthetic upgrades will be denied when a lower‑cost medically appropriate option exists. The plan favors the use of a medically adequate lower‑cost item when it meets the member's needs.

Operationally, this means providers must supply physician orders and supporting documentation (e.g., therapist evaluation, home evaluation, trials, residual limb/skin integrity data for prosthetics, caregiver training for pediatric standing programs) so that requests can be evaluated against the device‑specific criteria and the general medical necessity test. Certain items (for example, enclosed beds, many prosthetics, ROMTech/other NOS items, and specified repair codes) require mandatory secondary review by a medical director or therapy advisor per the policy.

The descriptions and examples above reflect the policy’s definitions and application of the general medical necessity standard and related reasonableness considerations in this DME/Orthotics/Prosthetics coverage guideline.

Defined Terms

Definitions

DMEDurable Medical Equipment: items durable, primarily used for a medical purpose, appropriate for home use, and generally not useful in the absence of illness or injury.

OrthoticsRigid 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.

ProstheticsCustom-made artificial limbs or other assistive devices that replace a body part or function as a result of traumatic injuries, vascular disease, diabetes, cancer or congenital disorders.

ROMTech deviceTelerehabilitation device referenced under 'Other Equipment' (codes E1399, A9900); coverage is contingent on device-specific evidence and criteria.

JACOWheelchair-mounted Assistive Robotic Arm (Kinova, Inc.) — device for which the policy states coverage is not medically necessary due to insufficient evidence of safety and improved outcomes.

Policy Changes and Material Revisions

08/25revised/addedLatest

Added general medical necessity criterion I.A.1 ('Equipment is necessary and reasonable…'), added codes E0680 and E0681 to non-pneumatic compression devices, and added I.A.1 note; other code and wording updates recorded in the 08/25 revision.

05/24revised/added

Added Lumbar-Sacral Orthotics (LSO) section with numerous L-codes, renamed Spinal Orthotics to 'Other Spinal Orthotics', updated manual wheelchair criteria and deleted codes E1091 and K0009; multiple coding and section reorganizations.

11/24revised

Numeric & Clinical Thresholds to Use in Authorizations

Key thresholds

WCD age threshold≥ 18 years

WCD authorization duration30 days initial; ongoing authorizations in 30-day increments up to a total of 90 days when criteria met

LVEF example for WCD considerationLeft ventricular ejection fraction (LVEF) ≤ 35% (listed as part of qualifying cardiac scenarios)

Heavy duty walker weight thresholdMember/enrollee weight > 300 pounds for heavy duty walker (E0148, E0149)

Wheelchair useful lifetime for replacementReasonable useful lifetime ≥ 5 years for replacement consideration

Repair vs replacement cost thresholdRepair cost less than replacement cost allowed; for prosthetics, repair cost > 60% of replacement cost triggers replacement rules

OpenPayer

Durable Medical Equipment (DME) and Orthotics & Prosthetics Coverage Criteria

Device- and Condition-Specific Medical Necessity Rules

Relevant HCPCS / L-code Groups and Examples

Prior Authorization, Documentation & Billing Alerts

Clinical & Policy Context

Defined Terms

Policy Changes and Material Revisions

Numeric & Clinical Thresholds to Use in Authorizations

Durable Medical Equipment (DME) and Orthotics & Prosthetics Coverage Criteria

Device- and Condition-Specific Medical Necessity Rules

Relevant HCPCS / L-code Groups and Examples

Prior Authorization, Documentation & Billing Alerts

Clinical & Policy Context

Defined Terms

Policies to Read With This Document

Policy Changes and Material Revisions

Numeric & Clinical Thresholds to Use in Authorizations