Prior Authorization for Durable Medical Equipment (DME)
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This draft policy governs prior authorization requirements and medical necessity determination processes for durable medical equipment (DME) 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 Criteria
Coverage criteria and submission rules
Coverage and medical necessity are determined using the BCBSRI online authorization tool criteria, InterQual criteria, and—when applicable for Medicare Advantage—CMS National and Local Coverage Determinations.
For Medicare Advantage
- When applicable, CMS National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) are used to determine medical necessity for Medicare Advantage members.
- Refer to the attached Coding section list for referenced NCDs/LCDs (including Noridian Jurisdiction A documents) when applicable.
Medical Necessity Determination Sources
Medical necessity sources
Medical necessity determinations rely on the online tool criteria and, for Medicare Advantage members, applicable CMS determinations.
Medicare Advantage specific
- When applicable, reference CMS National Coverage Determinations (NCDs) to determine medical necessity for Medicare Advantage members.
- When applicable, reference CMS Local Coverage Determinations (LCDs) (including Noridian Jurisdiction A documents) to determine medical necessity for Medicare Advantage members.
Codes and Coverage Conditionality
| Refer to attached grid (external XLSX) listing codes requiring prior authorization; codes listed are covered when applicable medical criteria are met. |
Provider Submission & Authorization Rules
Submission channels — use online tool; fax if not participating
Participating providers must submit DME prior authorization requests using the BCBSRI online prior authorization tool. Providers who are not participating should fax requests to Utilization Management at (401) 272-8885 as the exception path.
- Online tool URL referenced in policy for participating providers.
- Fax to Utilization Management: (401) 272-8885 for non-participating providers.
Prior authorization requirement and PCP exemption (effective 10/1/2025)
Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial Products. Effective 10/1/2025, Fully-Funded Commercial Products may not require prior authorization when the requesting physician is a BCBSRI-contracted Primary Care Provider in the listed specialties; all other Commercial Products and Medicare Advantage Plans continue to require prior authorization.
- Requirement: Prior authorization required for Medicare Advantage Plans.
- Recommendation: Prior authorization recommended for Commercial Products.
- Exemption effective date: 10/1/2025 for Fully-Funded Commercial Products when request is by a BCBSRI-contracted PCP.
Eligible PCP specialties for exemption
The PCP specialties included in the Fully-Funded Commercial exemption are Internal Medicine, Pediatric Medicine, Family Practice, Obstetrics and Gynecology, Doctor of Osteopathic Medicine, NP/PCP, and PA.
- Internal Medicine
- Pediatric Medicine
- Family Practice
- Obstetrics and Gynecology
- Doctor of Osteopathic Medicine
- NP (Nurse Practitioner)/PCP (Primary Care Physician or Provider)
- PA (Physician Assistant)
Documentation and Submission Records
Document medical necessity and authorizations in the online tool; fax option for non‑participating providers
Participating providers must record medical necessity criteria and authorization entries in the BCBSRI online authorization tool; non‑participating providers should fax requests to Utilization Management at (401) 272-8885. CMS National/Local Coverage Determinations may be referenced when applicable for Medicare Advantage members.
- Document InterQual and online tool criteria entries in the BCBSRI authorization system.
- For Medicare Advantage, record applicable CMS NCD/LCD references as part of the authorization documentation when required.
Key Terms and Definitions
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