ModifiedCentenePolicy CP.MP.107

Durable Medical Equipment and Orthotics and Prosthetics (DME/O&P) Coverage Criteria

Governs medical necessity, coverage criteria, coding implications, and review requirements for durable medical equipment, orthotics, and prosthetics for Centene-affiliated health plans and their members.

Policy Summary

PayerCentene

PolicyDurable Medical Equipment and Orthotics and Prosthetics (DME/O&P) Coverage Criteria

Policy CodePolicy CP.MP.107

Change TypeMultiple additions, removals, and revisions across device sections and coding

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with required clinical documentation (OT/PT evaluations, home assessment, device trial evidence) for applicable DME/O&P requests.

SourceLink

POLICY UPDATE CHANGES

Invasive home ventilator criteria (E0465) were removed and moved to CP.MP.184 Home Ventilators.

Statement that current evidence does not support the effectiveness of intrapulmonary percussive ventilation (E1399) was added.

Policy statement and general criteria (I.A.1 and I.A.2) were updated and ambulatory assist products table updated; multiple devices and sections were retired or moved.

New Lumbar-Sacral Orthotics (LSO) section and many associated HCPCS codes were added.

Manual wheelchair initial and replacement request criteria were updated and multiple wheelchair/power seat codes were changed or deleted (e.g., deleted E1091, K0009; replaced K1032/K1033 with E0678/E0679).

Wearable cardioverter defibrillator criteria and HCPCS code K0606 were added.

ROMTech device (E1399, A9900) section, criteria, and coding were added.

Multiple codes and sections removed including pediatric wheelchair codes, oxygen tent, certain surgical supplies, whirlpool tub, and others.

Added general criteria I.A.1 stating equipment is necessary and reasonable with corresponding note and added codes E0680 and E0681 to non-pneumatic compression devices.

manyHCPCS codes referenced

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Coverage Criteria and Device-specific Rules

General DME/O&P Medical Necessity Criteria

Covered when ALL of the following are met:

General criteria: 1. Equipment is necessary and reasonable for the treatment of an illness or injury or to improve functioning of a physical deficit; 2. Education regarding use of the device provided with demonstrated understanding; 3. A trial of the requested device with demonstrated ability to use it safely and effectively.

From general criteria A in policy

Wearable Cardioverter Defibrillator (WCD) Initial Criteria

Covered when ALL of the following are met (example: Wearable Cardioverter Defibrillator initial request):

WCD initial: A. Member is ≥18 years with increased risk of sudden cardiac death; B. One of: awaiting cardiac transplant; previously implanted ICD removed due to infection awaiting re-implantation; newly indicated ICD delayed due to systemic infection or LVEF ≤35% with MI within 40 days or CABG/PCI within 90 days or newly diagnosed potentially reversible nonischemic cardiomyopathy undergoing optimal medical therapy; C. Device is FDA approved and used according to indications.

Initial requests medically necessary for 30 days when all met

WCD Ongoing Use Criteria

Covered for ongoing WCD when ALL are met:

WCD ongoing: Initial criteria continues to be met; adherence confirmed by device reports and attestation from ordering provider; plan of care updated with progression towards definitive treatment pathway.max total 90 days

Ongoing requests considered medically necessary for 30-day increments up to 90 days

Enclosed Bed Criteria

Enclosed beds covered when ALL of the following are met:

Enclosed bed general: A. Standard bed or standard hospital bed cannot meet positioning needs due to disability; B. Less intensive alternatives tried and ruled out with documentation (e.g., bed rails, mattress on floor, removal of hazards, bed alarms, monitors, environmental and behavioral interventions); C. Qualifying diagnosis such as cerebral palsy, developmental delay, genetic/neurological disorder causing uncontrolled movement, uncontrolled seizure disorder, or severe behavior disorder; D. Healthcare provider evaluation (typically OT/PT) including functional status, home evaluation, and caregiver education on safe enclosure use; E. Name and invoice for the bed/enclosure requested and mandatory secondary review by a medical director and/or therapy advisor; use limited to night/sleep and short naps and not for discipline or restraint.

Enclosed bed documentation and restrictions per policy

Custom Foot Orthotics Criteria

Custom foot orthotics covered when ALL of the following are met:

Custom foot orthotics: A. Member has an indicated foot condition (examples include juvenile idiopathic arthritis, pes cavus, rheumatoid arthritis, plantar fasciitis with symptoms ≥1 month, or posterior tibial tendon dysfunction as specified); B. Documentation that activity modification, NSAIDs, prefabricated orthotics, and stretching have failed to improve symptoms.symptoms ≥1 month for plantar fasciitis

Codes L3000-L3020 etc.

Upper Extremity and Myoelectric Prosthetic Criteria

Upper extremity/myoelectric prosthetics covered when ALL of the following are met:

Initial prosthetic request: 1. Functional needs cannot be met with activity modification or compensatory techniques; 2. Requested prosthesis is anticipated to meet the member's functional needs; 3. Clinical exam documents appropriate residual limb length, stable limb volume, ability to tolerate weight, adequate skin integrity, strength, and ROM, appropriate environment, and cognitive ability to use device; 4. Comprehensive prosthetic rehabilitation plan including pre-prosthetic training, specified method of control, functional task training, home exercise program, and follow-up schedule.

All replacement requests also require criteria including irreparable wear or change in condition and repair cost > 60% of replacement cost

Technologies Considered Not Medically Necessary

Not covered when evidence insufficient:

Insufficient evidence: Non-wearable external defibrillator with integrated ECG analysis (E0617); non-pneumatic compression devices (E0678–E0681); myoelectric rehabilitation systems (E0738, E0739); ROMTech PortableConnect device / ROMTech (E1399, A9900) — listed as not medically necessary due to insufficient evidence or lack of demonstrated effectiveness over alternatives.

These items are explicitly listed as not medically necessary in policy

Infusion Pump Criteria

Ambulatory and implantable infusion pumps covered when indications met:

Ambulatory infusion pump uses: Medically necessary when used for: A) administration of deferoxamine for acute iron poisoning; B) regional hepatic-directed chemotherapy for unresectable primary hepatocellular carcinoma or colorectal metastases limited to the liver; C) with opioid drugs for intractable cancer pain; D) prolonged infusions (≥8 hours) when proven to have improved clinical efficacy; or E) intermittent infusions meeting specified criteria for controlled-rate administration.

Ambulatory pump HCPCS E0780, E0781

Implantable infusion pump medical necessity

Implantable infusion pumps — Covered when ALL of the following are met:

Indications: One of the following indications must be met: 1) Chemotherapy for liver cancer (primary hepatocellular carcinoma or Duke's Class D colorectal cancer limited to liver) when unresectable or patient refuses excision; 2) Intrathecal anti-spasmodic therapy for chronic intractable spasticity after failure of less invasive therapy with a documented 6-week trial of noninvasive methods and a favorable intrathecal drug trial prior to implantation; 3) Other uses when the drug is reasonable and necessary, it is medically necessary that the drug be administered by an implanted pump, and the pump is FDA-approved for the drug and intended purpose.

Implantable pump HCPCS E0782, E0783, E0785, E0786

Implantable infusion pump contraindications

Contraindications — Implantable infusion pump not to be implanted if ANY of the following exist:

Contraindications: Known allergy or hypersensitivity to the drug being used; active infection; body size insufficient to support the weight/bulk of the device; presence of another implanted programmable device when contraindicated.

Contraindications listed in policy

Oximeter coverage

Oximeter — Covered when ANY of the following monitoring uses are present:

Oximeter Uses: A. To monitor individuals on a home ventilator or with a tracheostomy; B. To determine appropriate home oxygen requirements; C. To wean an individual from home oxygen; D. To monitor an unstable respiratory condition.

Oximeter HCPCS = E0445

Oximetry not medically necessary

Oximeter — Not medically necessary when used for ANY of the following:

Oximetry Not Covered: A. Oximetry when used as a diagnostic procedure; B. Monitoring of a stable respiratory condition; C. Asthma management.

Explicit not medically necessary uses for oximetry

Standard walker medical necessity

Standard walker — Covered when ALL of the following are met:

Standard walker criteria: A. Mobility-related activities of daily living (MRADLs) in the home cannot be met due to a mobility limitation; B. Walker can be safely used by the member/enrollee; C. Functional mobility deficit will be sufficiently resolved with use of a walker.

Standard walker HCPCS = E0130, E0135, E0141, E0143

Heavy duty walker medical necessity

Heavy duty walker — Covered when ALL of the following are met:

Heavy duty walker criteria: Meets standard walker criteria AND member/enrollee weighs more than 300 pounds for HCPCS E0148/E0149. For E0147 (multiple braking/variable wheel resistance), meets standard walker criteria and member is unable to use a standard walker due to severe neurologic disorder or other condition causing restricted use of one hand.>300 pounds

Heavy duty walker HCPCS = E0148, E0149, E0147

Manual wheelchair initial criteria

Manual wheelchair — Initial requests covered when ALL of the following are met:

Manual wheelchair initial: A. Mobility limitation interferes with ability to participate in MRADLs and: 1) limitation cannot be met with a cane or walker; 2) manual wheelchair will significantly improve ability to participate in MRADLs; 3) home provides adequate access and maneuvering space; 4) willingness by member/enrollee or caregiver to use a manual wheelchair; AND B. One of: 1) caregiver able to assist; 2) member able to safely and efficiently self-propel.

Manual wheelchair initial HCPCS listed in policy

Manual wheelchair replacement criteria

Manual wheelchair — Replacement requests covered when ONE of the following is met:

Manual wheelchair replacement: A. Replacement necessary due to loss, theft, or irreparable damage with documentation supporting continued medical necessity and replacement with same or similar equipment; OR B. All of the following: 1) Replacement due to end of reasonable useful lifetime (≥5 years) or change in status requiring different equipment with current growth features maximized; 2) Mobility limitation interferes with MRADLs and cannot be met with cane or walker and wheelchair will significantly improve MRADLs.>=5 years

Replacement criteria and reasonable useful lifetime threshold

Wheelchair repair criteria

Wheelchair and DME repairs — Covered when ALL of the following are met:

Repair criteria: A. Item is less than 5 years old (supported by age/date of purchase); B. Cost of repairs is less than cost of replacement; C. Documentation supports need for repairs due to normal wear and tear rather than abuse/misuse or overutilization.<5 years

One month's rental for a standard manual wheelchair is considered medically necessary while owned wheelchair is repaired; codes K0108, K0739, E1399 require secondary review

General medical necessity

Equipment is covered when ALL of the following are met:

General medical necessity (I.A.1): Equipment is necessary and reasonable for the diagnosis and treatment of the member's condition as specified in the corresponding device section.

New general criteria I.A.1 added to policy.

Manual wheelchair — initial and replacement (updated per sections A and B)

Manual wheelchair covered when ALL specified device-specific criteria are met per updated sections A and B.

Manual wheelchair initial request: Meets updated device-specific initial criteria (documentation of mobility limitation, inability to use cane/walker, home access, willingness to use wheelchair, and caregiver or self-propulsion capacity) and other policy requirements.

Initial criteria updated per policy revisions

Manual wheelchair replacement request: Meets reformatted and updated replacement criteria including documentation for loss/theft/irreparable damage or end of reasonable useful lifetime and prior authorization where applicable.

Replacement criteria reformatted

Device-specific stances

Specific device stances:

ROMTech device (E1399, A9900): New ROMTech device section and coding added; coverage is subject to the ROMTech device section criteria and requires mandatory secondary review when using miscellaneous codes.

See ROMTech device section for full criteria

Intrapulmonary percussive ventilation (E1399): Current evidence does not support effectiveness of intrapulmonary percussive ventilation devices; these are listed as not medically necessary.

Policy added statement on lack of supporting evidence (see cited evidence briefs)

Deluxe or aesthetic upgrades to durable medical equipment (for example: special lights, sounds, cameras, custom finishes, vibration pads, weighted blankets, or other nonclinical enhancements) do not meet the policy reasonableness test and are excluded from coverage. If a lower-cost medically appropriate alternative exists that will meet the member’s clinical needs, the higher-cost alternative (including deluxe features) will be denied.

The following device categories are stated as not medically necessary due to insufficient evidence supporting their safety or effectiveness: non-pneumatic compression devices (HCPCS E0678, E0679, E0680, E0681) and myoelectric rehabilitation systems (HCPCS E0738, E0739). Requests for these items will be denied as not medically necessary.

The policy includes a specific statement that intrapulmonary percussive ventilation (IPV) devices (reported under miscellaneous HCPCS E1399 for some products) are considered not medically necessary because current evidence does not support their effectiveness.

Several items and sections have been removed or relocated in the update. Examples include removal of the oxygen tent and the whirlpool tub sections, deletion of certain 'Other surgical supplies' codes, and removal of some pediatric wheelchair codes. Invasive home ventilator criteria (HCPCS E0465) were removed from this policy and moved to the separate policy CP.MP.184 Home Ventilators.

For Medicaid members/enrollees, state Medicaid coverage provisions take precedence where they conflict with this clinical policy. Providers should consult the applicable state Medicaid manual for any differing coverage rules.

Specific items listed as not medically necessary in this policy include: non-wearable external defibrillator with integrated ECG analysis (HCPCS E0617), non-pneumatic compression devices (HCPCS E0678–E0681), the cold pad pump (HCPCS E0236) for postoperative management, ROMTech PortableConnect / miscellaneous specialized supply (HCPCS E1399, A9900), myoelectric rehabilitation systems (HCPCS E0738, E0739), and ultrasonic nebulizers (HCPCS E0575). These items are denied when requested for coverage.

Ultrasonic nebulizers (HCPCS E0575) are considered not medically necessary because they do not provide a clinical advantage over small-volume nebulizers (HCPCS E0574) with compressor; requests for E0575 will be denied on that basis.

The policy specifies that oximetry (HCPCS E0445) is medically necessary when used as a monitoring/alarm device for specific unstable or ventilator-related situations (e.g., to monitor individuals on a home ventilator, to determine/home oxygen requirements, to wean from home oxygen, or to monitor an unstable respiratory condition). Conversely, oximetry is not medically necessary when used as a diagnostic procedure, for routine monitoring of a stable respiratory condition, or for asthma management.

The previous MyoPro Orthosis codes (L8701, L8702) were removed from the policy and the content was reorganized under a new Myoelectric Rehabilitation Systems section (HCPCS E0738, E0739). The policy now treats these myoelectric systems with an explicit 'not medically necessary' statement and updated coding.

HCPCS / CPT / Coding Tables

Burn Garments HCPCSHCPCSCovered

A6501	Burn garments HCPCS example
A6502	Burn garments HCPCS example
A6503	Burn garments HCPCS example
A6504	Burn garments HCPCS example
A6505	Burn garments HCPCS example
A6506	Burn garments HCPCS example
A6507	Burn garments HCPCS example
A6508	Burn garments HCPCS example
A6509	Burn garments HCPCS example
A6510	Burn garments HCPCS example

1–10 of 13

1/2

Non-wearable External DefibrillatorHCPCSNot Covered

E0617

Non-wearable external defibrillator with integrated ECG analysis

Wearable Cardioverter DefibrillatorHCPCSCovered

K0606

Wearable Cardioverter Defibrillator (WCD)

Non-pneumatic Compression DevicesHCPCSNot Covered

E0678	Non-pneumatic compression device HCPCS
E0679	Non-pneumatic compression device HCPCS
E0680	Non-pneumatic compression device HCPCS
E0681	Non-pneumatic compression device HCPCS

Accessible Blood Glucose MonitorHCPCSCovered

E2100

Blood glucose monitor with integrated voice synthesizer

Ultraviolet Panel LightsHCPCSCovered

E0691	Ultraviolet panel light HCPCS
E0692	Ultraviolet panel light HCPCS
E0693	Ultraviolet panel light HCPCS
E0694	Ultraviolet panel light HCPCS

Cold Pad PumpHCPCSNot Covered

E0236

Cold pad pump

Enclosed Beds and Related CodesHCPCSCovered

E0316	Enclosed bed HCPCS
E1399	Durable medical equipment, miscellaneous
E0328	Enclosure component HCPCS (when combined with E0316 or E1399)
E0329	Enclosure component HCPCS (when combined with E0316 or E1399)

Cervical Traction/Collar CodesHCPCSCovered

E0849	Cervical traction equipment HCPCS
L0170	Cervical collar custom molded
L0190	Cervical collar custom molded
L0200	Cervical collar custom molded

Custom Foot OrthoticsHCPCSCovered

L3000	Foot orthotics, custom
L3001	Foot orthotics, custom
L3002	Foot orthotics, custom
L3003	Foot orthotics, custom
L3010	Foot orthotics, custom
L3020	Foot orthotics, custom

Upper Extremity ProstheticsHCPCSCovered

L6000	Upper extremity prosthetics HCPCS example
L6010	Upper extremity prosthetics HCPCS example
L6020	Upper extremity prosthetics HCPCS example
L6708	Upper extremity prosthetics HCPCS example

Myoelectric Rehabilitation SystemsHCPCSNot Covered

E0738	Myoelectric Rehabilitation Systems HCPCS
E0739	Myoelectric Rehabilitation Systems HCPCS

Infusion Pump CodesHCPCSCovered

E0780	Ambulatory infusion pump HCPCS
E0781	Ambulatory infusion pump HCPCS
E0782	Implantable infusion pump HCPCS
E0783	Implantable infusion pump HCPCS
E0785	Implantable infusion pump HCPCS
E0786	Implantable infusion pump HCPCS

Other Specific DME CodesHCPCSCovered

K0455	Parenteral pump for medication administration
L7900	Vacuum erection device HCPCS
L7902	Vacuum erection device HCPCS

Spinal OrthoticsHCPCS

L0700	Spinal orthotics HCPCS example
L0710	Spinal orthotics HCPCS example
L0720	Spinal orthotics HCPCS example

Implantable infusion pumpsHCPCS

E0782	Implantable infusion pump
E0783	Implantable infusion pump
E0785	Implantable infusion pump
E0786	Implantable infusion pump

Parenteral pumpsHCPCS

K0455

Parenteral pump for medication administration

Vacuum erection devicesHCPCSCovered

L7900	Vacuum erection device
L7902	Vacuum erection device

NebulizersHCPCS

E0575	Nebulizer, ultrasonic
E0574	Small-volume nebulizer

IPPBHCPCSCovered

E0500	IPPB & supplies
E0550	IPPB & supplies

OximeterHCPCSCovered

E0445

Oximeter

IPV devices / miscellaneousHCPCSNot Covered

E1399

Intrapulmonary percussive ventilation devices / miscellaneous DME

WalkersHCPCSCovered

E0130	Standard walker
E0135	Standard walker
E0141	Standard walker
E0143	Standard walker
E0147	Walker, multiple braking system/variable wheel resistance
E0148	Heavy duty walker
E0149	Heavy duty walker

Wheelchair and DME repair codesHCPCS

K0108	Wheelchair seating repairs/adjustments
K0739	DME repairs

Power wheelchair componentsHCPCS

E2298

Power seat elevator on power wheelchair

Other Equipment / ROMTech / MyoPro coding updatesHCPCS

E1399	Intrapulmonary percussive ventilation / ROMTech device (added statement of insufficient evidence)
A9900	Specialized supply or equipment (ROMTech device)
E0240	Specialized supply or equipment (added)
L8701	MyoPro Orthosis (removed; replaced by Myoelectric Rehabilitation Systems coding)
L8702	MyoPro Orthosis (removed)

Ventilators and Non-pneumatic compression device codesHCPCS

E0465	Invasive home ventilator (moved to CP.MP.184)
E0678	Non-pneumatic compression device (replaced K1032)
E0679	Non-pneumatic compression device (replaced K1033)
E0680	Non-pneumatic compression device (added)
E0681	Non-pneumatic compression device (added)

Cardiac and Myoelectric RehabilitationHCPCSCovered

K0606	Wearable cardioverter defibrillator
E0738	Myoelectric Rehabilitation Systems
E0739	Myoelectric Rehabilitation Systems

Lumbar-Sacral Orthotics (LSO) codesHCPCSCovered

L0450	Lumbar-Sacral Orthotic (LSO) code (one of many L0xxx codes added)
L1005	LSO-related or spinal orthotic code (included in list)

Facial Prosthetics and related codesHCPCSCovered

L8040	Facial prosthetics (added to new Facial Prosthetics section)
L8041	Facial prosthetics
L8499	Other prosthetic supplies

Codes referenced in this segmentmixed

None listed

No CPT/HCPCS/ICD-10 codes are present in this document segment.

WCD initial coverage duration

Initial coverage duration30 days initial when WCD criteria met

Prior Authorization, Documentation, and Billing Actions

Prior Authorization

Prior Authorization and Secondary Review — Prior authorization required for many DME/O&P items and some require secondary review

Prior authorization is required for many DME/O&P items; some requests require secondary review or routing changes to other policy(s). Items moved to other policies (for example, invasive home ventilator E0465 moved to CP.MP.184) will be routed per current plan prior authorization procedures. Providers should submit prior authorization requests with complete clinical documentation to avoid delays or denials.

Prior authorization required for listed DME items and select implantable infusion pumps (see policy code sections).
Requests for items moved to other policies will be routed accordingly (e.g., E0465 → CP.MP.184).

Denial Risk

Lower-cost Alternative Requirement — Deny higher-cost item if a medically necessary, lower-cost item will meet member needs

If a medically necessary, lower-cost alternative will meet the member's needs, the higher-cost or deluxe item may be denied as not reasonable. Providers should document why a lower-cost alternative is clinically insufficient when requesting higher-cost features.

Rental, Purchase, Repair, and Replacement Rules

Rule	Guidance
Purchase vs Rental Determination
Policy emphasizes selection of the most reasonable, cost‑effective medically appropriate item. If a lower‑cost item meets the member's needs, the higher‑cost item will be denied. Coverage decisions are subject to the member's benefit terms and applicable laws/regulations.

Equipment	Rental Guidance
Standard manual wheelchair (owned wheelchair under repair)
One month's rental of a standard manual wheelchair is considered medically necessary while a member's owned wheelchair is being repaired. Requests for repairs using codes K0108, K0739, or E1399 require mandatory secondary review.

Situation	Repair/Rental Guidance
Wheelchair repair (normal wear and tear, <5 years old)
Repairs are covered when information documents normal wear and tear (not abuse/misuse), item age/date of purchase supports repair (<5 years), and repair cost is less than replacement. While repairs are performed, one month's rental for a standard manual wheelchair is medically necessary.

Segment	Notes
Supplemental rental/purchase rules
No specific rental or purchase rules are provided within this document segment beyond general guidance to choose the most reasonable, cost‑effective medically appropriate item and to follow benefit terms and applicable legal/regulatory requirements.

Orthotics and prosthetics replacement guidance

Replacement guidance (O&P)Orthotics and prosthetics are replaced as needed based on wear or condition (replacement medically necessary when irreparable wear or change in condition exists)

Repair vs replaceReplacement indicated when repair cost > 60% of replacement cost or prosthesis no longer functions properly

Documentation requirementsRequests must document proper care per manufacturer, evidence of irreparable damage, and continued functional need

Manual wheelchair replacement interval

Replacement interval (manual wheelchair)Reasonable useful lifetime threshold for manual wheelchair replacement is every 5 years

Required Documentation and Supporting Records

Documentation Required

Supply mandatory documentation for enclosed beds and prosthetic replacements; expect secondary review

Mandatory documentation is required for enclosed beds and prosthetic replacements; many items also require secondary review by a medical director or therapy advisor per policy.

Enclosed bed requests: OT/PT evaluation, home evaluation, caregiver education, name and invoice; mandatory secondary review.
Prosthetic replacements: documentation of continued need, proper care, irreparable wear or change in condition, and repair cost analysis.

Documentation Required

Include age/purchase evidence and clinical justification for repair/replacement

For repair and replacement requests, include age/date of purchase and clinical justification showing the need for repair versus replacement or evidence of loss/theft/irreparable damage.

Provide age/date of purchase to support repair eligibility (<5 years) or replacement after reasonable useful lifetime (≥5 years).
Include evidence supporting loss/theft or irreparable damage when applicable.

Items Considered Not Medically Necessary

Not covered items listed in the policy include non-pneumatic compression devices (HCPCS E0678–E0681), the non-wearable external defibrillator with integrated ECG analysis (HCPCS E0617), the ROMTech PortableConnect / miscellaneous specialized supply (HCPCS E1399 / A9900), and myoelectric items (HCPCS E0738, E0739). These are explicitly identified as not medically necessary and not covered.

The policy reiterates that intrapulmonary percussive ventilation devices (HCPCS E1399) are not covered because current evidence does not support their effectiveness. Additionally, ultrasonic nebulizers (HCPCS E0575) are identified as not medically necessary due to lack of advantage over standard small-volume nebulizers (HCPCS E0574).

For emphasis, the policy lists intrapulmonary percussive ventilation devices (HCPCS E1399) multiple times as not medically necessary, reflecting the added statement that existing evidence does not support IPV effectiveness and that such devices should not be covered.

The policy again highlights that intrapulmonary percussive ventilation devices (reported under HCPCS E1399) lack sufficient evidence of benefit and therefore are not covered; this duplication underscores the policy stance on IPV devices.

A further repeat within the not-covered listings restates that intrapulmonary percussive ventilation (HCPCS E1399) is not supported by current evidence and is therefore considered not medically necessary and not covered.

Definitions and Terminology

Durable Medical Equipment (definition)

DME definitionEquipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, is appropriate for home use, and is generally not useful in the absence of illness or injury

Durability criterionAn item is durable if it can withstand repeated use (the type of item that could normally be rented); expendable medical supplies are not considered durable

Prescriber requirementDME is prescribed by a physician and must be necessary and reasonable for treatment of an illness or injury

Orthotic devices (definition)

Orthotic devices definitionRigid or semi-rigid devices used to support a weak or deformed body part or to restrict or eliminate motion in a diseased or injured body part

Examples

Medical Necessity — General and Device Examples

General DME Medical Necessity

Covered when ALL of the following are met:

General DME Medical Necessity: Equipment necessary and reasonable for treatment or function; education provided with demonstrated understanding; trial of device with demonstrated safe/effective use.

Applies to all DME/O&P

Enclosed Beds Specific Criteria

Enclosed beds covered when ALL criteria are met:

Enclosed Beds Specific Criteria: Standard bed cannot meet positioning needs; less intensive alternatives tried and ruled out with documentation; qualifying diagnoses present; OT/PT evaluation with home evaluation and caregiver education provided; name and invoice for requested bed; mandatory secondary review required; use limited to night/sleep and short naps and not for restraint.

Enclosed bed HCPCS = E0316, E1399, E0328/E0329 when applicable

Actions, Reminders, and Important Notes for Providers

Prior Authorization

Obtain prior authorization and expect secondary review where specified

Prior authorization is required for DME/O&P and many items require secondary review; verify routing changes and regulatory alignment before submission to avoid denials.

Obtain prior authorization and be prepared for secondary review on specified items.
Confirm correct policy for moved codes (e.g., E0465 moved to CP.MP.184).
Ensure submissions comply with plan documents and legal/regulatory requirements.

Prior Authorization

Verify authorization routing for moved codes before submitting

Check for prior authorization routing changes — items moved to other policies (for example, invasive ventilator E0465 moved to CP.MP.184); submit under the correct policy to prevent processing errors.

Do not submit moved codes under this policy; route requests according to the destination policy (e.g., CP.MP.184 for E0465).
Verify code changes added or removed in recent revisions prior to submission.

Background and Scope

Durable medical equipment (DME) is reusable equipment prescribed for a medical purpose and appropriate for use in the member’s home. Orthotics are devices that support or restrict motion of body parts, and prosthetics replace a missing body part or function. Equipment must be necessary, reasonable, and demonstrably beneficial for treatment or function, and providers must document trials, training, and functional improvements when seeking coverage.

The policy update removed multiple items and code sections, including the oxygen tent and whirlpool tub sections and certain pediatric wheelchair codes; invasive home ventilator criteria (E0465) were moved to CP.MP.184. These removals and relocations are noted to help providers route requests and supporting documentation to the appropriate policy or to recognize that certain codes are no longer included in CP.MP.107.

Policy Summary

PayerCentene

PolicyDurable Medical Equipment and Orthotics and Prosthetics (DME/O&P) Coverage Criteria

Policy CodePolicy CP.MP.107

Change TypeMultiple additions, removals, and revisions across device sections and coding

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with required clinical documentation (OT/PT evaluations, home assessment, device trial evidence) for applicable DME/O&P requests.

SourceLink

On This Page

Denial Risk

Enclosed Bed Upgrade Exclusions

Enclosed beds are covered only as basic beds when medically necessary. Upgrades for aesthetic or non-medical purposes and features that do not meet DME rules are excluded.

Examples of excluded upgrades: special lights/sounds, fans, cameras, two-way talk monitors, vibration pads, weighted blankets, custom wood/finishes/engravings, specialty external coverings.
Requests for enclosed beds require documentation of healthcare provider evaluation, home evaluation, and caregiver education; mandatory secondary review by a medical director and/or therapy advisor.
Name of and invoice for the bed or enclosure must be provided with the request.

Denial Risk

Denial triggers — Failure to follow medical necessity criteria, coding changes, or prior authorization routing may trigger denial

Denials may be triggered by failure to meet general medical necessity criteria, missing or insufficient documentation, failure to follow prior authorization or routing requirements, or when requested items are moved to other policies. Coding or policy changes may also trigger denials or rerouting.

Common triggers: incomplete medical records, lack of device-specific required documentation, failure to trial less invasive therapies when required (e.g., intrathecal pump step therapy).
Policy or coding updates may change authorization routing or coverage status — verify current policy and codes before submission.

Documentation Required

Enclosed Bed Documentation — Required provider evaluations, home evaluation, and caregiver training documentation

Providers must document medical necessity per the general criteria (I.A.1 and I.A.2) and device-specific requirements. For enclosed beds, include provider evaluation, home evaluation, caregiver training documentation, diagnosis, and the name and invoice for the requested bed/enclosure. All enclosed bed requests require mandatory secondary review.

General documentation: evidence that equipment is necessary and reasonable; education provided and trial of device with demonstrated ability to use safely and effectively.
Enclosed bed-specific: healthcare provider evaluation (often OT/PT) with functional status, home evaluation, documentation of caregiver education on proper use, and invoice/name of requested bed.
All enclosed bed requests undergo mandatory secondary review by a medical director and/or therapy advisor.

Documentation Required

Wheelchair replacement and repair documentation — Documentation evidencing age/purchase, loss/theft, irreparable damage, or repair justification

Replacement and repair requests for wheelchairs require documentation evidencing age or purchase date, loss/theft, irreparable damage, or justification that repair cost exceeds replacement criteria. Wheelchair repairs are medically necessary when under five years old and repair cost is less than replacement; one month rental of a standard manual wheelchair is medically necessary if owned wheelchair is being repaired.

Replacement criteria examples: loss/theft with documentation; irreparable damage; change in medical status requiring different equipment; useful lifetime ≥5 years.
Repair documentation: age/date of purchase, rationale for repair (normal wear vs. abuse), and cost estimate showing repair < replacement.
Codes K0108, K0739, and E1399 for repairs or miscellaneous requests require mandatory secondary review.

Documentation Required

Power wheelchair documentation — Licensed/certified professional involvement required for assessment/prescription/training

Power wheelchair components (e.g., power seat elevator E2298) require assessment, prescription, trials, and training by a licensed/certified medical professional (such as a physical or occupational therapist). Include documentation of professional involvement and training.

Licensed/certified professional must be involved in assessment, prescription, trials, and training.
Provide clinical justification that the component is required and not duplicative of existing equipment.

Step Therapy

Intrathecal pump step therapy — Trial of noninvasive methods required prior to intrathecal pump for anti-spasmodic drugs

Intrathecal pump (implantable infusion pump) coverage for anti-spasmodic drugs requires step therapy: a documented 6-week trial of noninvasive methods (e.g., oral anti-spasmodic drugs) that failed to control spasticity or caused intolerable side effects, plus a favorable response to an intrathecal drug trial prior to pump implantation.

Prior to implantation, document a 6-week trial of noninvasive methods that failed or were intolerable.
Document favorable response to a trial intrathecal dose before approving pump implantation (HCPCS E0782/E0783/E0785/E0786).

Prosthetic Replacement Criteria: A. Replacement requested because current prosthesis no longer functions properly or residual limb changes prevent accommodation, or irreparable wear or significant change in condition; B. Repair cost exceeds 60% of replacement cost OR irreparable damage; C. Prosthesis has been properly cared for per manufacturer recommendations; D. Medical documentation supports continued need, motivation, and appropriate functional level; E. Replacement with same or similar prosthesis/components. Mandatory secondary review required for upper extremity and myoelectric prosthetics.repair cost >60%

Prosthetic replacement HCPCS listed in policy

Implantable infusion pump

Implantable infusion pump coverage follows device-specific criteria:

Implantable infusion pump: Indications include chemotherapy for specified liver cancers, intrathecal anti-spasmodic therapy after required trials, or other uses when the drug and implanted pump are reasonable, necessary, and FDA-approved for the drug and purpose; contraindications (e.g., allergy, active infection, inadequate body size) preclude implantation.

See implantable infusion pump criteria and contraindications in policy (HCPCS E0782/E0783/E0785/E0786)

Manual wheelchairs

Covered when ALL of the following are met:

Manual wheelchairs: Initial manual wheelchair criteria: mobility limitation interfering with MRADLs not correctable with cane/walker; wheelchair will significantly improve MRADLs; home access and willingness to use wheelchair documented; caregiver assistance or safe self-propulsion documented. Replacement criteria: loss/theft/irreparable damage with documentation OR end of reasonable useful lifetime (≥5 years) or change in status requiring different equipment; repairs covered when <5 years old, repair cost less than replacement, and wear is due to normal use. One month's rental allowed during repair.>=5 years for replacement; <5 years for repair

Manual wheelchair HCPCS and repair codes K0108, K0739 referenced

Examples of equipment medical necessity

Device-specific medical necessity follows general criteria plus section-specific requirements; examples include:

Examples and notes: One month's rental for a standard manual wheelchair is medically necessary while a member's owned wheelchair is being repaired; intrapulmonary percussive ventilation devices (E1399) are noted as unsupported by current evidence and listed as not medically necessary; ROMTech device coding and MyoPro/Myoelectric coding updates are documented in device sections.

See device-specific sections for full criteria and applicable HCPCS codes