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Prior Authorization for Durable Medical Equipment (DME)
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Defines prior authorization requirements and medical necessity criteria for durable medical equipment (DME) for Blue Cross Blue Shield - Rhode Island members, affecting participating providers and other requestors submitting authorization requests.
No material clinical or coverage changes in this revision.
Coverage Criteria for DME
General coverage criteria
Durable medical equipment is considered medically necessary when the applicable criteria in the BCBSRI online authorization tool (or CMS NCD/LCD for Medicare Advantage when applicable) are met.
When Medicare Advantage member
- Applicable CMS National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs) apply and must be used to determine medical necessity for Medicare Advantage members where indicated.
Codes and Coding References
| See attached Excel grid of codes requiring prior authorization (link provided in policy). |
Prior Authorization & Provider Actions
How to request prior authorization
Requests for DME must be submitted using the BCBSRI online prior authorization tool when the requestor is a participating provider. Nonparticipating providers must fax the request to Utilization Management at (401) 272-8885 to complete the prior authorization process. The online tool URL is referenced in the policy for submitting requests.
- Use BCBSRI online prior authorization tool if you are a participating provider.
- If not participating, fax requests to Utilization Management at (401) 272-8885.
- Online tool link referenced in policy: https://www.bcbsri.com/BCBSRIWeb/Login.do?redirectTo=/providers/preauth/preauthProviderOverview.jsp
PA requirements by product and PCP exemption
Prior authorization is required for Medicare Advantage Plans and is recommended for Commercial Products. For Fully‑Funded Commercial Products only, prior authorization may not be needed effective 10/1/2025 when the requesting physician is a BCBSRI contracted primary care provider in one of the listed specialties; all other Commercial Products (including Self‑Funded) and Medicare Advantage still require prior authorization.
- Prior authorization required: Medicare Advantage Plans.
- Prior authorization recommended: Commercial Products.
- Fully‑Funded Commercial exemption (effective 10/1/2025) applies when requesting physician is a BCBSRI contracted PCP in these specialties: Internal Medicine; Pediatric Medicine; Family Practice; Obstetrics and Gynecology; Doctor of Osteopathic Medicine; NP/PCP; PA.
- Exemption does not apply to Self‑Funded Commercial Products or Medicare Advantage Plans.
Coding and prior authorization
The policy’s attached coding grid (linked in the Coding section) identifies items that require prior authorization; absence of a code from that list does not imply coverage.
- Refer to the attached coding grid in the Coding section for the list of codes requiring prior authorization.
- If a code is not on the list, that omission is not a statement of coverage or noncoverage.
Definitions
Medical Necessity Determination
Medical necessity determination
Medical necessity for DME is determined primarily by InterQual criteria available in the BCBSRI online authorization tool; CMS NCD/LCDs apply for Medicare Advantage when indicated.
If Medicare Advantage member or when specified
- Reference and apply applicable CMS National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs) (including Noridian Jurisdiction A determinations and noncovered items) to determine medical necessity.
Operational note: Use the online tool for requests if you are a participating provider; nonparticipating providers should fax requests to Utilization Management.
Documentation & Submission Instructions
Use online tool if participating provider; otherwise fax to Utilization Management
Authorization requests must follow the BCBSRI online prior authorization tool requirements when submitted via the online tool; providers who are not participating must fax requests to Utilization Management at (401) 272-8885.
- Use the online authorization tool (participating providers) at the BCBSRI provider portal link.
- Fax alternative for nonparticipating providers: (401) 272-8885.
- Refer to the attached coding grid to identify which codes require prior authorization.
Items Not Covered
This policy does not list specific items as not covered. Providers should refer to the attached coding grid for items that require prior authorization and to external Medicare guidance for noncovered items applicable to Medicare Advantage members. For Medicare Advantage, consult CMS National and Local Coverage Determinations and Noridian Healthcare Solutions noncovered items for determinations of noncoverage.
When questions remain about whether a specific code or item is not covered, use the BCBSRI coding spreadsheet linked in the policy and the Noridian noncovered items reference to verify coverage status; absence of a code from the attached list does not imply coverage.
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