Prior Authorization for Durable Medical Equipment (DME)
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This draft policy governs the prior authorization request process and medical-necessity review for durable medical equipment for BCBSRI Medicare Advantage and Commercial members.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medical necessity for DME
DME is medically necessary when the applicable criteria are met.
InterQual criteria generally guide medical-necessity determinations. For Medicare Advantage members, applicable CMS National or Local Coverage Determinations may apply. For policies listed in the Related Policies section, BCBSRI medical criteria apply.
The attached prior-authorization list identifies DME items that require prior authorization. The absence of a code from the list does not imply coverage; the request must still meet applicable coverage and medical-necessity requirements.
Prior Authorization and Provider Actions
Plan-Specific Prior Authorization Rules
Prior authorization is required for Medicare Advantage Plans and recommended for Commercial Products. For Fully-Funded Commercial Products, requests may not be needed beginning 10/1/2025 when submitted by a BCBSRI-contracted primary care provider in an eligible specialty; authorization remains required for Self-Funded Commercial Products, Medicare Advantage Plans, and other exempt-ineligible situations.
- Exempt eligible specialties credentialed as primary care providers: Internal Medicine, Pediatric Medicine, Family Practice, Obstetrics and Gynecology, Doctor of Osteopathic Medicine, Nurse Practitioner/Primary Care Provider, and Physician Assistant.
Submit Through the Appropriate Channel
Submit DME requests through the BCBSRI online prior authorization tool when you are a participating provider. All other providers must fax requests to Utilization Management to complete the prior authorization process.
- Online tool: https://www.bcbsri.com/BCBSRIWeb/Login.do?redirectTo=/providers/preauth/preauthProviderOvervie w.jsp
- Fax: (401) 272-8885
Submit Clinical Support
Include clinical documentation supporting the medical-necessity criteria with each authorization request. BCBSRI criteria are found in the online authorization tool; InterQual criteria generally apply, and CMS National or Local Coverage Determinations apply when required for Medicare Advantage members.
- For policies identified in the Related Policies section, use BCBSRI medical criteria.
- For Medicare Advantage, reference applicable CMS National Coverage Determinations, Noridian Healthcare Solutions Jurisdiction A Local Coverage Determinations, and Noridian Jurisdiction A Noncovered Items.
Identify the Equipment and Code
Identify the DME and applicable billing code before submitting the request. Use the attached 2026 Prior Authorization of Durable Medical Equipment (DME) list in the Coding section to determine whether the item requires prior authorization and to locate the applicable code.
- 2026 list: https://www.bcbsri.com/providers/sites/providers/files/support/2026/08/DRAFT%20Codes%20Requiring%20Prior%20Authorization%20for%20DME.Effective.12.1.2026.xlsx
Code Listing Does Not Guarantee Coverage
A code’s presence or absence on the DME prior-authorization list does not determine coverage. Listed codes are covered only when the applicable medical criteria are met, and omission of a code does not imply that the item is covered.
Benefits and Eligibility Control Payment
Payment is governed by the member’s eligibility and applicable benefit documents, not by this policy alone. Review the Benefit Booklet, Evidence of Coverage, Subscriber Agreement, and applicable employer agreement for Medical Equipment, Medical Supplies, and Prosthetic Devices benefits; these documents supersede this policy.
- Call the provider call center for member-specific benefits and eligibility.
- If services are determined not medically necessary or are medically necessary but non-covered, do not charge the member unless the member was informed and agreed in writing in advance to continue treatment at their own expense, consistent with the applicable participation agreement.
Medical-Necessity Criteria Not Met
DME is medically necessary only when the applicable criteria are met. Requests may be denied when BCBSRI criteria, generally applicable InterQual criteria, or applicable CMS National or Local Coverage Determination criteria are not satisfied.
- For Medicare Advantage members, CMS criteria may control medical-necessity determinations.
- For policies identified in the Related Policies section, BCBSRI criteria apply instead of the generally applicable criteria.
Policy Background
Durable medical equipment is considered medically necessary when the applicable criteria in the BCBSRI online authorization tool are met. InterQual criteria generally guide medical-necessity determinations, while applicable CMS National or Local Coverage Determinations apply for Medicare Advantage members. For policies identified in the Related Policies section, BCBSRI medical criteria apply.
DME Medical Necessity
DME medical necessity
Durable medical equipment is considered medically necessary when the applicable criteria are met.
InterQual criteria generally apply. Applicable CMS National or Local Coverage Determinations apply for Medicare Advantage members; BCBSRI medical criteria apply for policies specifically identified in the Related Policies section.
Required Documentation and Coding
Document medical necessity with the authorization request
Submit a prior authorization request with clinical information demonstrating that the applicable medical-necessity criteria are met. Use the BCBSRI online authorization tool when available to participating providers; all other providers should fax the request to Utilization Management at (401) 272-8885.
- Support the applicable BCBSRI criteria.
- Support applicable InterQual criteria.
- Support applicable CMS National or Local Coverage Determination criteria.
Use the 2026 DME authorization coding list
Use the attached 2026 DME prior-authorization coding list to identify the requested equipment and applicable billing code. A listed item or code remains subject to applicable medical-necessity criteria and benefit coverage.
- Reference the 2026 Prior Authorization of Durable Medical Equipment (DME) list.
- Confirm that the request satisfies medical criteria and the member’s benefit requirements.
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