Prior Authorization for Durable Medical Equipment (DME)
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This policy governs prior authorization requirements and the use of medical necessity criteria for durable medical equipment for Blue Cross Blue Shield - Rhode Island members, affecting providers requesting DME for Medicare Advantage and Commercial products.
No material clinical or coverage changes in this revision.
Coverage and Authorization Overview
General coverage stance
Coverage is determined by meeting medical necessity criteria in the BCBSRI online authorization tool; benefits may vary by contract.
Codes and Coding Guidance
| See external spreadsheet 'Codes Requiring Prior Authorization for DME' linked in policy. |
| No codes listed |
Sources and Determination of Medical Necessity
Sources of medical necessity criteria
Medical necessity is determined using the following sources:
What Providers Must Do
How to submit prior authorization requests
Submit DME prior authorization requests using the BCBSRI online prior authorization tool (available only to participating providers). If you are not a participating provider, fax the request and supporting clinical documentation to Utilization Management at (401) 272-8885. The online tool link is provided in the policy and the Coding section lists items requiring authorization; absence of a code from that list does not imply coverage.
- Participating providers: use BCBSRI online prior authorization tool.
- Non-participating providers: fax requests to Utilization Management at (401) 272-8885.
- Online tool link and coding list referenced in policy; absence of a code on the list is not coverage assurance.
Prior authorization required for MA; PCP exemption for some Fully‑Funded Commercial
Prior authorization is mandatory for Medicare Advantage Plans and recommended for Commercial Products. Beginning 10/1/2025, Fully-Funded Commercial Products may be exempt from prior authorization when the requesting physician is a BCBSRI‑contracted Primary Care Provider in the listed specialties; prior authorization remains required for Self‑Funded Commercial and all Medicare Advantage plans.
- Exemption effective 10/1/2025 applies only to Fully‑Funded Commercial Products and BCBSRI‑contracted PCPs.
- Included PCP specialties: Internal Medicine; Pediatric Medicine; Family Practice; Obstetrics and Gynecology; Doctor of Osteopathic Medicine; Nurse Practitioner/PCP; Physician Assistant.
- Prior authorization still required for Self‑Funded Commercial Products and Medicare Advantage.
Medical necessity determined via InterQual and CMS NCD/LCD (as applicable)
Medical necessity determinations are made using InterQual criteria available in the BCBSRI online authorization tool; for Medicare Advantage members, applicable CMS National and Local Coverage Determinations (NCD/LCD) are used and are also available in the online tool.
- InterQual criteria are the default standard for medical necessity in the online authorization tool.
- For Medicare Advantage, reference applicable CMS NCDs and LCDs (including Noridian Jurisdiction A determinations and noncovered items) when applicable.
Clinical Documentation and Submission Requirements
Provide clinical rationale and supporting documentation via online tool (fax if non-participating)
Submit clinical rationale and supporting documentation through the BCBSRI online prior authorization tool; if you are not a participating provider, fax the request and supporting documentation to Utilization Management at (401) 272-8885.
- Documentation must align with InterQual criteria or applicable CMS NCD/LCD as found in the online authorization tool
- Non-participating providers must fax both the request and supporting clinical documentation to Utilization Management
Key Terms
Non-Covered Items and Notes
The policy states that the attached coding grid is intended to identify items that require prior authorization, but it also expressly cautions that the absence of a code from that list does not imply coverage. Providers should therefore consult the COVERAGE section and the member’s benefit documents (Benefit Booklet, Evidence of Coverage, or Subscriber Agreement) to determine whether a specific item is a covered benefit for the member.
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