CurrentBaylor Scott & White Health PlanPolicy 028

Durable Medical Equipment and Over the Limit Supplies

Governs medical necessity and coverage considerations for durable medical equipment and requests for supplies that exceed plan limits for Baylor Scott & White Health Plan members, including Medicare and Medicaid considerations where applicable.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyDurable Medical Equipment and Over the Limit Supplies

Policy CodePolicy 028

Change TypeNo material changes

Effective Date03/01/2026

Next Review Date02/26/2027

Key ActionObtain prior authorization when required and document medical necessity, including physician evaluation within 6 months for over-the-limit supply requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

03/01/2026effective date

02/26/2027next review

02/26/2026last review

E1399highlighted HCPCS

Coverage Criteria

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DME general criteria: Item is prescribed by a physician or other authorized clinician; not available to the general public as over-the-counter unless mandated (e.g., diabetic supplies); meets the 42 CFR 414.202 definitions: can withstand repeated use; is primarily and customarily used to serve a medical purpose; generally not useful in the absence of illness or injury; appropriate for use in the patient's home; expected lifetime of at least 3 years.

Purchase or rental at BSWHP discretion; replacement, repair, and modification covered only for material change in clinical status or customary wear and tear; duplicates not covered.

Over-the-Limit Supplies

Over-the-limit supplies may be covered when ALL of the following are met:

Over-the-limit supply criteria: The treating physician has ordered a frequency/quantity that exceeds the benefit limit; the treating physician has seen and evaluated the member within 6 months prior to ordering the excess quantities; the physician has documented in the member's medical record the specific reason for the additional materials for that member.

For Medicaid plans consult the applicable TMPPM for item-specific over-the-limit criteria; when TMPPM lacks criteria, these requirements apply to other plans (including Medicare where NCD/LCD do not provide over-the-limit criteria).

The following items are not considered durable medical equipment (DME). This list is not all-inclusive and examples include: exercise equipment such as exercise cycles; functional electrical stimulation (FES) exercise devices (see examples in policy); household equipment with customary non‑medical purposes (for example: air purifiers, air conditioners, water purifiers, allergenic pillows, mattresses and waterbeds, and household fixtures such as escalators, elevators, saunas, swimming pools, ramps, stairs, and bathroom modifications); and miscellaneous items such as dentures, hearing aids, eyeglasses, and corrective lenses (unless covered by rider).

Stationary exercise devices and certain FES exercise devices (examples include the FES Power Trainer, ERGYS/REGYS, NeuroEDUCATOR, STimMaster Galaxy, RT200 Elliptical, RT300 FES Cycle Ergometer/"FES bicycle", RT600 Step and Stand Rehabilitation Therapy System, and SpectraSTIM) are not considered DME. These stationary devices are considered experimental and investigational for the prevention or reduction of muscle atrophy of the upper and lower extremities in individuals with hemiplegia or quadriplegia and for all other indications.

Coding

HCPCS Codes highlightedHCPCS

E1399	Durable medical equipment, miscellaneous — used for DME without a specific HCPCS code; specific situations apply (e.g., Volara device, RomTech Adaptive Rehab Device, vaginal/rectal probe sensors).
K0108	Miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a specific HCPCS code and are not included in another code.

Other code setsmixed

No codes listed

DME expected lifetime — key value

Expected lifetime>= 3 years

Regulatory basisAligned with 42 CFR 414.202 definition of DME

Implication for coverageItems must meet the >=3 year lifetime to be considered DME and eligible for purchase/rental discretion

Provider Actions

Prior Authorization

Prior Authorization Required as Specified

Prior authorization requirements vary by product line. Check the plan-specific Prior Authorization List and the member's Evidence of Coverage (EOC) or Summary Plan Description (SPD) for whether prior authorization is required for the requested DME or supply.

Prior authorization requirement: Varies by product line — see 'Prior Authorization List' and member EOC/SPD.
Medicare: follow applicable NCD/LCD if present; if none, use policy criteria.
Medicaid: follow state TMPPM guidance where applicable.

Documentation Required

Provider Documentation and Coverage Expectations

Providers must ensure documentation supports medical necessity and that requested items are not available OTC unless mandated (e.g., diabetic supplies). Use established review tools (e.g., InterQual®) or applicable NCD/LCD when performing medical necessity determinations.

DME considered medically necessary when prescribed by authorized clinician and meets 42 CFR 414.202 definitions.
Purchase vs rental, replacement, repair, and duplicates: follow EOC – replacements/repairs covered only for material change in clinical status or wear and tear.

Documentation Required

Over-the-Limit Supply Documentation Required

For requests that exceed published quantity limits (over-the-limit supply requests), the treating physician must both order the increased frequency/quantity and have evaluated the member within the prior 6 months, with specific documentation in the medical record explaining the need for additional materials.

Treating physician ordered frequency exceeds benefit limit.
Physician seen and evaluated member within 6 months prior to ordering.
Physician documented specific reason for additional supplies in the medical record.

Denial Risk

Denial Triggers

Requests will be denied when the item is available OTC (unless mandated), excluded by the member's EOC/SPD, or does not meet medical necessity criteria per applicable NCD/LCD, TMPPM, or the policy criteria below.

OTC availability without mandate (e.g., non-covered OTC items) may trigger denial.
EOC/SPD exclusions govern coverage — if excluded, request will be denied.
Medicare/Medicaid: follow NCD/LCD or TMPPM; absence of criteria does not imply coverage.

Background

Durable medical equipment (DME) must meet regulatory and policy definitions to be eligible for coverage. Per applicable guidance, DME generally must: be capable of withstanding repeated use, be primarily and customarily used to serve a medical purpose, not be useful in the absence of illness or injury, be appropriate for use in the patient’s home, and have an expected lifetime of at least 3 years. Coverage decisions incorporate these criteria alongside prescriber order and plan terms (for example, purchase versus rental discretion and replacement rules).

Definitions

DME — definition and key attributes

Definition (summary)Durable medical equipment (DME) can withstand repeated use; is primarily and customarily used to serve a medical purpose; is generally not useful in the absence of illness or injury; is appropriate for home use; and has an expected lifetime of at least 3 years.

Repeated useEquipment must be able to withstand repeated use (could be rented and used by successive patients)

Primary medical purposePrimarily and customarily used to serve a medical purpose (not for general household use)

Home useAppropriate for use in a patient’s home

Not useful when healthyGenerally not useful to a person in the absence of illness or injury

Medical Necessity

DME medical necessity

DME is considered medically necessary when ALL of the following CMS-derived definitions are met:

DME definition criteria: Can withstand repeated use; is primarily and customarily used to serve a medical purpose; generally is not useful in the absence of illness or injury; is appropriate for use in the patient's home; has an expected lifetime of at least 3 years.>= 3 years

Must be prescribed by an authorized clinician and not be available over-the-counter unless mandated; purchase or rental at BSWHP discretion; replacement only for material change in clinical status or customary wear and tear.

Rental and Purchase Rules

Equipment	Rental vs Purchase	Replacement / Repairs	Notes
General durable medical equipment (DME)	Purchase or rental at the discretion of BSWHP	Replacement, repair, and modification covered ONLY for material change in clinical status or customary wear and tear; duplicates not covered	Item must meet 42 CFR 414.202 definitions (repeated use, medical purpose, not useful absent illness/injury, appropriate for home, expected lifetime ≥ 3 years). Medical necessity determinations may use InterQual or applicable Medicare NCD/LCD

Code / Item	Coding guidance	Policy rule / stance	Notes
E1399 — Durable medical equipment, miscellaneous	Use when no specific HCPCS code exists; used for certain devices (e.g., Volara®, RomTech Adaptive Rehab Device) per policy; vaginal/rectal probe sensors when applicable	Neutral — allowable coding pathway when rules are met; subject to specific policy provisions (see Medical Policy 236 for excluded devices)	E1399 follows rules per 42 C.F.R.; apply InterQual or plan criteria as applicable for medical necessity
K0108 — Miscellaneous wheelchair options/accessories/parts	Use for wheelchair miscellaneous parts that lack a specific HCPCS and are not included in another code	Neutral — code recommended for miscellaneous wheelchair parts	Do not substitute K0108 when a more specific code exists

Replacement

General DME replacement and exceptions

Replacement ruleReplacement, repair, and modification covered ONLY for a material change in clinical status or customary wear and tear

DuplicatesDuplicate DME items are not a covered benefit

Purchase vs rentalPurchase or rental decisions are at the discretion of BSWHP

Medicaid <21 exceptionFor Medicaid beneficiaries under age 21, numerical limits and replacement time periods can be exceeded if medically necessary

Documentation

Documentation Required

Physician evaluation and documentation required for excess supplies

See Over-the-Limit Supplies documentation: the physician must have seen and evaluated the member within 6 months prior to ordering excess supplies and must document the specific reason for the additional materials in the medical record.

Physician evaluation must be within 6 months prior to the order for excess supplies.
Physician must document the specific reason for additional materials in the member's medical record.

Not Covered

The following items are not covered under this DME policy: exercise equipment (including exercise cycles and the FES devices listed in the policy), stationary FES exercise devices deemed experimental/investigational, household non‑medical equipment (examples: air purifiers, air conditioners, water purifiers, allergenic pillows, mattresses and waterbeds, and household fixtures such as escalators, elevators, saunas, swimming pools, ramps, stairs, and bathroom modifications), and miscellaneous items such as dentures, hearing aids, eyeglasses, and corrective lenses unless specifically covered by a rider to the member’s plan.

Policy Summary

PayerBaylor Scott & White Health Plan

PolicyDurable Medical Equipment and Over the Limit Supplies

Policy CodePolicy 028

Change TypeNo material changes

Effective Date03/01/2026

Next Review Date02/26/2027

Key ActionObtain prior authorization when required and document medical necessity, including physician evaluation within 6 months for over-the-limit supply requests.

SourceLink

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