Prior Authorization for Durable Medical Equipment (DME)
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - Rhode Island policy alerts
Know when Blue Cross Blue Shield - Rhode Island releases new policies or updates existing guidance.
Monitor payer policy activity
This policy governs prior authorization and medical-necessity review for durable medical equipment requested for Blue Cross Blue Shield of Rhode Island Medicare Advantage and Commercial members.
No material clinical or coverage changes in this revision.
Coverage Criteria
BCBSRI Medical-Necessity Criteria
Durable medical equipment is considered medically necessary when the applicable BCBSRI medical-necessity criteria are met.
ALL of the following
- The criteria in the BCBSRI online authorization tool are met.
Medicare Advantage CMS Criteria
For Medicare Advantage members, CMS medical-necessity criteria are used when applicable and are available through the online authorization tool.
ALL of the following applicable requirements
- The applicable CMS National Coverage Determination (NCD) criteria are met.
- The applicable CMS Local Coverage Determination (LCD) criteria are met, including the Local Coverage Determination from Noridian Healthcare Solutions, Jurisdiction A, when applicable.
- The item is not identified as a noncovered item in the applicable Noridian Healthcare Solutions, Jurisdiction A Noncovered Items guidance.
The attached list in the Coding section identifies items that require prior authorization. The absence of a code from that list does not imply coverage. Refer to the Coverage section for coverage details.
Provider Actions
Prior Authorization Requirements
Prior authorization is required for Medicare products and is recommended for Commercial Products. Prior authorization remains required for Self-Funded Commercial Products and Medicare Advantage Plans, subject to applicable plan requirements.
Fully-Funded Commercial PCP Exemption
Effective October 1, 2025, a prior authorization request may not be needed for Fully-Funded Commercial Products when submitted by a BCBSRI-contracted physician credentialed as a primary-care provider in an eligible specialty.
- Eligible credentialed primary-care specialties: Internal Medicine; Pediatric Medicine; Family Practice; Obstetrics and Gynecology; Doctor of Osteopathic Medicine; Nurse Practitioner/Primary Care Provider; and Physician Assistant.
Unsupported block type: documentation
Submit the Authorization Request
Submit DME authorization requests through the applicable channel before proceeding with services subject to prior authorization. Participating providers should log in to the BCBSRI online prior authorization tool; all other providers should fax the request to Utilization Management at (401) 272-8885 to complete the authorization process.
- Review the policy’s Coding section and the online tool for items identified as requiring prior authorization.
Support Medical Necessity
Support medical necessity with the criteria applicable to the member’s product and the requested DME. DME is considered medically necessary when the applicable criteria are met.
- Use the BCBSRI online authorization tool, which generally contains InterQual medical-necessity criteria.
- For Medicare Advantage members, use applicable CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), including Noridian Healthcare Solutions, Jurisdiction A criteria and noncovered-item determinations, as available through the online authorization tool.
- For policies specifically identified in the Related Policies section, apply BCBSRI medical criteria.
- Confirm the requested equipment, supplies, or prosthetic devices are supported by the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement.
Criteria Not Met May Result in Denial
If the applicable medical-necessity criteria are not met, the request may be denied and the service or equipment may not be authorized for coverage.
- Verify that the request satisfies the applicable BCBSRI, InterQual, CMS NCD/LCD, and benefit-document requirements before submission.
Code Listing Does Not Guarantee Coverage
The presence or absence of a code in the policy’s Coding section does not establish coverage. Benefits may vary by group or contract and remain subject to the member’s applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement.
- A code listed as requiring prior authorization does not guarantee that the item is covered.
- Refer to the Coverage section and the member’s applicable benefit documents for coverage and benefit limitations.
Medical Necessity Requirements
General DME Medical Necessity
Durable medical equipment is considered medically necessary when the applicable BCBSRI criteria are met.
Specific equipment criteria are maintained in the online authorization tool rather than reproduced in this policy.
Medicare Advantage Medical Necessity
CMS criteria apply when applicable to Medicare Advantage members.
For Medicare Advantage plans, medical-necessity criteria are found in associated CMS National and Local Coverage Determinations and may be accessed through the online authorization tool.
Documentation and Submission
Submit through the applicable BCBSRI channel
Submit the DME prior authorization request through the BCBSRI online prior authorization tool if you are a participating provider. All other providers should fax the request to Utilization Management at (401) 272-8885.
- Online tool: https://www.bcbsri.com/BCBSRIWeb/Login.do?redirectTo=/providers/preauth/preauthProviderOvervie w.jsp
- Fax: Utilization Management at (401) 272-8885
Support the request with medical-necessity information
The request must address the applicable medical criteria. The coding grid identifies items requiring prior authorization, but codes listed in the grid are covered only when the applicable medical criteria are met.
- Use the BCBSRI online authorization tool for the applicable criteria.
- For Medicare Advantage members, reference applicable CMS National or Local Coverage Determinations when required.
- Do not treat the coding grid as a guarantee of coverage.
Policy Background
This is an administrative policy governing prior authorization and medical-necessity review for durable medical equipment requested for Blue Cross Blue Shield of Rhode Island Medicare Advantage and Commercial members. DME is considered medically necessary when the applicable criteria in the BCBSRI online authorization tool are met; for Medicare Advantage members, applicable CMS National or Local Coverage Determinations may also apply.
Coverage Limitations
A DME code appearing on the prior-authorization list does not by itself establish coverage. Benefits remain subject to the member's applicable benefit booklet, Evidence of Coverage, or Subscriber Agreement, and benefits may be unavailable under the member's applicable group or contract benefit documents.
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.