Durable Medical Equipment and Supplies Coverage Criteria
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This policy governs coverage, prior approval, documentation, and program rules for durable medical equipment (DME) and related supplies for Clear Health Alliance beneficiaries enrolled in a Prepaid Health Plan (PHP). It affects providers billing DME and members receiving DME and supplies.
Policy Summary
Payerclearhealthalliance
PolicyDurable Medical Equipment and Supplies Coverage Criteria
Policy CodePolicy Policy 5A-1
Change TypeNo material change
Effective Date
Next Review Date
Key ActionSubmit completed CMN/PA with required clinical documentation and therapist letters of medical necessity for items requiring prior approval.
No material clinical or coverage changes in this revision.
~46sections/pages referenced in TOC
19document chunks in this window
6rental threshold (months)
YesEPSDT applies (<21)
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Coverage Criteria
Coverage organization
The policy organizes coverage by sections describing when items are covered and when they are not covered, with general criteria, device‑specific criteria, and Medicaid/EPSDT exceptions.
Policy structure: Coverage is organized into: (a) general coverage criteria; (b) specific device or category criteria with documentation and prior approval requirements; and (c) a 'Not Covered' section listing general and device‑specific exclusions. EPSDT (beneficiaries <21) may override limits when medically necessary and not unsafe/experimental.
See Sections 3.0–5.3 and 4.0 for full details.
Coverage categories and rules
Durable medical equipment and supplies are grouped into coverage categories with rental/purchase and servicing rules; unlisted items require prior approval.
Categories: a) Inexpensive/routinely purchased items are purchased for the beneficiary; b) Capped rental/purchase items: rented when anticipated need ≤6 months, may be rented or purchased if need >6 months but once rental starts a subsequent purchase request is denied until accrued rental equals allowable purchase price; c) Equipment requiring frequent/substantial servicing (e.g., oxygen) are rented; d) Related supplies are covered when provided for use with beneficiary‑owned equipment; e) Service and repair covered over useful life; f) Individually priced items are reviewed and manually priced.see node text
Refer to Attachment A Section C for HCPCS, lifetimes, quantity limits; unlisted items need prior approval or EPSDT review for <21.
EPSDT special provision
Special Medicaid provision for beneficiaries under age 21 (EPSDT).
EPSDT: For beneficiaries under 21, EPSDT requires coverage of medically necessary services to correct or ameliorate a condition identified through screening; EPSDT may override policy limits if the service is medically necessary and is not unsafe, ineffective, or experimental; request an EPSDT review via NCTracks for items not listed in Attachment A Section C.age <21
EPSDT does not require coverage of unsafe, ineffective, or experimental items.
General DME Coverage
Covered when ALL of the following are met:
General DME coverage criteria: a. Item ordered by a physician, physician assistant, or nurse practitioner; b. Item is medically necessary to maintain or improve medical, physical or functional level and appropriate for use in noninstitutional settings; c. A documented face‑to‑face encounter related to the primary reason for DME occurred within six months prior to initiation; d. Ordering provider reviews need at least annually.
See Subsection 5.3 for device‑specific documentation requirements.
Hospital and Pediatric Bed Criteria
Hospital and pediatric beds are covered when the specific medical necessity criteria and required documentation are met.
Fixed Height Hospital Bed: Medical necessity documented when beneficiary requires head and/or foot adjustments not feasible in an ordinary bed to alleviate pain, promote alignment, or prevent bedrest complications.
Subsection 5.3.1.a
Variable Height (Manual Crank) Hi‑Lo Bed: 1) Beneficiary meets fixed height bed criteria; and 2) Variable height is necessary for ambulation or transfer in/out of bed.
Subsection 5.3.1.b
Semi‑Electric Hospital Bed: 1) Condition requires frequent changes in body position; 2) Immediate changes in head/foot position are needed and delay cannot be tolerated; 3) Beneficiary can independently operate electric controls.
Subsection 5.3.1.c
Total Electric Hospital Bed:
Pediatric bed medical necessity
Pediatric beds are covered when ALL of the following are documented and prior approval is obtained:
Pediatric bed basic criteria: 1) Prescriber order documenting hospital grade crib, safety enclosure, pediatric specialty bed or related supplies as most appropriate; 2) Diagnosis supports need for additional safety/positioning features (e.g., severe spasticity, thrashing, uncontrolled movements, cognitive impairment, unsafe behaviors); 3) Letter of medical necessity or PT/OT evaluation detailing how each requested feature is necessary and why a regular bed/hospital bed with rails is insufficient (therapist must be independent of supplier); 4) Documentation that the environment supports use; 5) Documentation that family/caregiver can safely and appropriately use equipment.
Prior approval required.
Group 1 coverage
Group 1 Pressure‑Reducing Support Surfaces are covered when ANY of the following apply (no prior approval required).
Group 1 indications: a) Beneficiary is completely immobile (cannot change position without assistance); OR b) Limited mobility plus one or more of: impaired nutritional status, fecal/urinary incontinence, altered sensory perception, compromised circulatory status, inability to respond to pain; OR c) Any stage pressure ulcer on trunk/pelvis plus one or more of: impaired nutritional status, altered mental status, fecal/urinary incontinence, altered sensory perception, compromised circulatory status.
Group 1 overlays/mattresses must be rented when anticipated need ≤6 months except specific pad items which are purchase‑only; documentation retained in provider records.
Group 2 medical necessity
Group 2 support surfaces require prior approval; initial approvals are limited and conservative treatment steps must have been tried.
Group 2 initial approval paths: Path A: multiple Stage II ulcers on trunk/pelvis that have worsened or remained same over past month AND on a comprehensive ulcer treatment program ≥1 month including appropriate Group 1 support surface; OR Path B: large or multiple Stage III or IV ulcers on trunk/pelvis; OR Path C: recent myocutaneous flap or skin graft for pressure ulcer (surgery within past 60 days) AND was on Group 2/3 support surface prior to discharge (within past 30 days).
Prior approval required; initial approval up to 6 months; renewals up to 3 months; rental rules apply.
Group 3 (air-fluidized) medical necessity
Air‑fluidized beds (Group 3) require strict criteria and prior approval; initial and renewal approvals are typically brief.
Air‑fluidized bed criteria: a) Stage III or IV pressure sore, or status post muscle/skin flap repair of stage III/IV; b) Bedridden or chair‑bound from severely limited mobility; c) Physician prescribes after comprehensive assessment and after conservative program tried without success (education, weekly assessment, turning/positioning, Group 2 if appropriate, topical wound care, moisture management, nutritional assessment); d) Conservative program ≥1 month with no improvement; e) Trained adult caregiver available; f) Physician directs regimen and re‑evaluates monthly; g) All alternative equipment considered and ruled out; and h) No contraindications (e.g., coexisting pulmonary disease, wet/moist dressings not occluded, inadequate structural/electrical support, unwilling/unable caregiver).
Prior approval required; initial/renewals typically limited to 1 month; continued use covered until ulcer healed with documentation.
Manual wheelchair medical necessity
Manual wheelchairs are covered when ALL of the following basic criteria are met (prior approval required).
Basic manual wheelchair criteria: a) Mobility limitation significantly impairs ability to perform ≥1 MRADL (toileting, feeding, dressing, grooming, bathing); b) Limitation not sufficiently resolved by cane or walker; c) Beneficiary's environment is accessible for wheelchair use; d) Use of wheelchair reasonably expected to significantly improve MRADLs; e) Sufficient upper extremity function to self‑propel or caregiver available to assist.
Prior approval required for all wheelchairs; payment for only one wheelchair at a time (no backup).
Wheelchair subtypes and tilt-in-space
Subtypes and additional features (examples) have specific clinical and measurement thresholds and documentation requirements.
Subtype/add‑on criteria: Examples include: Standard Hemi (lower seat height 17–18 in) when required for propulsion; Lightweight when beneficiary cannot self‑propel standard and can safely self‑propel lightweight; High‑strength lightweight or Ultra‑lightweight when beneficiary spends ≥6 hours/day and needs features; Heavy‑duty when weight >250 lbs or severe spasticity; Extra heavy‑duty when weight >300 lbs; Tilt‑in‑space requires ≥6 hours/day use plus positioning, deformity, skin integrity or cardiorespiratory benefits. Clinical eval and MSRP required; PT/OT evaluator must be independent of supplier.>=6 hours/day for some categories
Provider to submit clinical wheelchair evaluation and MSRP quote for prior approval.
Manual wheelchair rental
Manual wheelchair rentals are time‑limited under prior approval.
Manual wheelchair rental duration: Prior approval for rental of a manual wheelchair is granted for a maximum of nine months when all basic manual wheelchair coverage criteria are met.maximum 9 months
Oversized wheelchair medical necessity
Oversized manual wheelchairs require documentation of measurements and manufacturer capacity and prior approval.
Oversized wheelchair criteria: Beneficiary meets weight requirements for requested wheelchair; beneficiary height, weight and body measurements included; dimensions of requested equipment and manufacturer's specified weight capacity submitted; and all basic manual wheelchair coverage criteria met.>451 lbs
Prior approval required.
Power wheelchair prior approval
Power wheelchairs require comprehensive prior approval documentation including a face‑to‑face physician exam and environmental assessment.
Power wheelchair face‑to‑face requirement: A face‑to‑face in‑person examination by the treating physician documented in a narrative note must be submitted; the note must indicate mobility exam was the primary reason, document strength, mobility, functional deficits, ambulatory status, why power wheelchair is needed versus cane/walker/manual wheelchair, and justification for each accessory. Evaluation must be completed prior to physician order.
Also submit onsite environmental assessment (doorway widths, thresholds, surfaces) and MSRP quote; supplier forms not acceptable.
Standard power wheelchair clinical criteria: a) Mobility limitation significantly impairs ≥1 MRADL; b) Limitation not resolved by cane or walker; c) Insufficient upper extremity function to self‑propel optimally configured manual wheelchair for a normal day; d) Mental and physical capability to safely operate and maintain the power wheelchair; e) Use reasonably expected to significantly improve MRADLs; f) Environment accessible to wheelchair use.
Prior approval required; payment for only one wheelchair at a time; not medically necessary if condition reversible and need <3 months.
Oversized Manual Wheelchair
Oversized manual wheelchair criteria (restated where applicable).
Oversized Manual Wheelchair Criteria: a) Beneficiary meets weight requirements for requested wheelchair with height, weight, and body measurements submitted; b) Dimensions of requested equipment and manufacturer's specified weight capacity submitted; and c) all basic manual wheelchair coverage criteria met.>451 lbs
Prior approval required.
Power Wheelchair Coverage
Power wheelchairs are covered when all required documentation and clinical criteria are met.
Power Wheelchair Prior Approval Requirements: a) Face‑to‑face in‑person treating physician exam documented in chart prior to order; b) Onsite written environmental assessment verifying accessibility and including measurements; c) Manufacturer's MSRP quote detailing requested wheelchair and accessories; d) Clinical justification why less‑intensive devices (cane, walker, manual wheelchair) are inadequate.
Supplier‑generated physician forms not acceptable.
Standard Power Wheelchair Coverage Criteria: a. Mobility limitation significantly impairs ≥1 MRADL; b. Not sufficiently helped by appropriately fitted cane or walker; c. Insufficient upper extremity function to self‑propel manual wheelchair for normal day; d. Able to safely operate and maintain the power wheelchair; e. Use expected to significantly improve MRADLs; f. Environment accessible for wheelchair use.
Prior approval required.
Complex Rehab Power Wheelchair
Complex rehab power wheelchairs require additional therapist evaluation and documentation beyond standard power wheelchair criteria.
Complex Rehab Requirements: a) Clinical wheelchair evaluation by a PT/OT experienced in rehab evaluations who has no financial relationship with the supplier; b) Letter of medical necessity from that therapist documenting need for complex features and accessories; c) Documentation of medical necessity for special features in clinic evaluation; and d) meet all Standard Power Wheelchair criteria.
Complex chairs include special drive interfaces, power tilt/recline, and other specialized features.
Heavy Duty Power Wheelchair
Heavy duty power wheelchairs have weight‑based prior approval requirements.
Heavy Duty Prior Approval: a) Documentation that beneficiary meets weight requirements for the heavy‑duty power wheelchair requested and medical necessity for a comparable standard size wheelchair; b) Beneficiary height, weight and body measurements included; c) Dimensions of equipment and manufacturer's specified weight capacity submitted.>300 lbs
Prior approval required.
Accessories, Seating, and Electronics
Accessories, seating and electronics are covered when medically necessary; many require prior approval and specific documentation.
Accessories covered with criteria: Batteries necessary to operate approved power wheelchair (many batteries require prior approval), battery chargers (replacement chargers prior approval), adjustable height armrests (prior approval and >4 hours/day use), arm troughs (no prior approval), cushions (general use >2 hours/day covered; positioning/skin protection cushions covered when indicated), head/neck supports (prior approval with criteria), reclining back (prior approval with criteria), elevating leg rests (covered with clinical indications), trunk/extremity supports (prior approval except positioning belts and safety vest), oversized accessories (prior approval with measurements), and other items as listed in policy and fee schedule.
Refer to fee schedule: items identified with an asterisk require prior approval.
Power Seating Systems
Power seating systems (tilt, recline, combination) require prior approval and meet all listed clinical criteria.
Power seating medical necessity: a. Requires tilt‑in‑space for positioning during daily activities; b. Significant trunk or hip musculoskeletal deformity or abnormal trunk tone requiring tilt to maintain postural control or spinal alignment; c. Unable to actively change upright seating position and at risk for loss of skin integrity; d. Has respiratory, digestive or cardiac dysfunction functionally improved with tilt/recline; e. Spends minimum of six hours per day in the wheelchair; f. No caregiver available to manually perform this function.>=6 hours/day
Prior approval required.
Power Seat Elevation
Power seat elevation coverage is age‑limited and requires prior approval.
Power seat elevation (ages 0–20): Covered for ages 0 through 20 when beneficiary cannot transfer without height adjustment or requires seat elevation to perform MRADLs; prior approval required.age 0-20
Electronics
Electronics for power wheelchairs are covered when replacement meets repair‑vs‑replace criteria and prior approval conditions.
Replacement electronics: a. Part cannot be repaired; b. Warranty has expired; c. Replacing the part significantly extends the life of the wheelchair; d. Cost to replace part is less than cost of a new comparable wheelchair.
Prior approval required for most electronics; refer to fee schedule.
Wheels, Tires, Casters
Wheels, tires, casters, and related replacement parts are covered when necessary for continued function of an approved wheelchair.
Wheels and related parts: Propulsion tires, drive wheel tires, caster tires, tubes, valves, inserts, wheel locks and replacement parts are covered when medically necessary for the beneficiary to function in the provided power wheelchair; these items do not require prior approval; replacement parts covered when part is nonfunctional due to normal wear and approved wheelchair remains appropriate.
Accessories
Other accessories: some items require prior approval and others do not; documentation must show medical necessity.
Accessories not requiring prior approval: Swing‑away hardware, ventilator trays, single‑adjustment wheelchair trays, hand rims are covered when medically necessary and typically do not require prior approval.
Accessories requiring prior approval: Gear reduction drive wheels, wheel braking systems, motor and gearbox replacements require prior approval and meet replacement electronics criteria (non‑repairable, warranty expired, cost‑effective vs new wheelchair).
Activity/Positioning and Hi-Lo Chairs
Activity/positioning and Hi‑Lo chairs for ages 0–20 require prior approval with therapist documentation.
Activity Chair indications: Covered when beneficiary meets any one criterion such as inability to safely sit in conventional seating, need for support for fine motor activities, decreased trunk strength, uses arms to maintain sitting balance, requires external support for alignment, lacks protective/righting reactions, or requires upright supported position for safe feeding.
All accessories must be medically justified.
Tilt/Recline accessory: Covered when beneficiary cannot maintain head control upright, requires pressure relief, compensates for tonal changes, or needs tilt for digestion/reflux.
Mobile base: Covered when medically necessary to move beneficiary safely or for medically necessary activities with family; prior approval rules apply for Activity/Positioning Chairs (ages 0–20).
Hi‑Lo feature:
Patient Lifts (Hydraulic/Mechanical)
Hydraulic/mechanical patient lifts require prior approval and are covered when transfers cannot be performed safely without lift.
Hydraulic lift: a. Beneficiary's condition requires periodic movement to improve or arrest deterioration; and b. Beneficiary or family cannot transfer the beneficiary safely.
Note: Powered lifts are not covered as caregiver convenience.
Pneumatic Compressors and Appliances
Pneumatic compression devices are covered only for refractory lymphedema and require prior approval with CMN/PA Block 24 checked.
General lymphedema indication: Covered only for refractory lymphedema of one or more limbs after less intensive treatments (elevation, custom compression garments) have been tried and found inadequate; device must be prescribed by physician with physician oversight, treatment plan, and monitoring; Block 24 of CMN/PA must be checked.
Prior approval required.
Pneumatic compression for scarring/venous insufficiency: a. Significant lower extremity ulceration; b. Repeated standard treatments (e.g., compression bandage) tried; c. Ulcers failed to heal after 6 months of continuous treatment.
Prior approval required.
TENS Units
TENS units require prior approval and specific clinical documentation; rental precedes purchase requests.
TENS unit: Attach documentation including specific diagnosis, onset/duration, areas of pain, prognosis, treatments tried and failed, statement of improved ADL tolerance, pain scale and body map; other required details as listed in policy. TENS must be rented for 30–60 days prior to requesting purchase.rental 30-60 days
Prior approval required.
Osteogenesis Stimulators
Osteogenesis stimulators require prior approval with radiographic/time‑based criteria for non‑union and spinal indications.
Non‑spinal electrical stimulator: Covered for non‑union of a long bone when radiographic evidence shows fracture healing ceased for ≥3 months (two radiograph sets ≥90 days apart showing no healing), failed fusion of non‑spinal joint with ≥9 months since last surgery, or congenital pseudarthrosis. An osteogenesis stimulator for non‑healed long bone fracture <6 months or lack of fusion <12 months is not medically necessary.radiographs separated by >=90 days
Prior approval required.
Spinal electrical stimulator: Covered when medical necessity documented for failed spinal fusion with ≥9 months since last surgery, multilevel fusion (≥3 vertebrae), or prior failed fusion at same site.>=9 months for failed fusion
Prior approval required.
Ultrasonic stimulator: Covered if two radiograph sets ≥90 days apart show no clinically significant evidence of healing; fracture not of skull or vertebrae; fracture not tumor related.
Continuous Passive Motion Devices (Knee)
Continuous passive motion (CPM) devices for knee are covered in a narrow postoperative window with monitoring.
CPM for total knee replacement: Covered for beneficiaries who received total knee replacement when use commences within two days post‑surgery and is limited to a three‑week period; Block 24 on CMN/PA must be checked indicating physician monitoring.use begins ≤2 days post‑op; ≤3 weeks duration
Prior approval required.
Canes, Crutches, Walkers
Canes, crutches and walkers are covered when they meet MRADL impairment, safe use, and functional improvement criteria; some items need prior approval.
Canes and Crutches: Covered when: a) Mobility limitation significantly impairs ≥1 MRADL; b) Beneficiary can safely use the device; c) Functional mobility deficit can be resolved by the device. If criteria not met, denied. Crutch substitute (lower leg platform) requires prior approval.
MRADLs defined in policy: toileting, feeding, dressing, grooming, bathing.
Walkers: Standard walkers covered if same MRADL criteria met and beneficiary can safely use walker; prior approval not required. Glides/skis require prior approval.
Heavy Duty Mobility Aids
Heavy‑duty mobility aids require measurement documentation and prior approval for higher weight capacities.
Heavy duty canes/crutches: Covered for beneficiaries weighing >250 pounds; prior approval required; CMN/PA must include beneficiary height, weight, body measurements and equipment dimensions and manufacturer's specified weight capacity.>250 lbs
Heavy duty walkers: To substantiate medical necessity include beneficiary height, weight, body measurements and manufacturer's specified weight capacity on CMN/PA form.
Prior approval requirements vary per fee schedule.
Gait Trainers and Miscellaneous DME
Gait trainers and miscellaneous DME have specific prior approval and therapist evaluation rules.
Gait trainer coverage: Gait trainer with accessories requires prior approval and may be covered for ages 0–20 if PT/OT evaluation documents: (a) need for moderate to maximal support due to impaired balance or pelvic/trunk instability or GMFCS ≥3; and (b) beneficiary can initiate movement without caregiver assistance and movement is purposeful. Therapist must be independent of equipment provider.age 0-20
Miscellaneous DME: Examples: cervical traction (for specified orthopedic diagnosis), transfer boards (when needed for transitions), paraffin bath and over‑tub whirlpool when physician documents benefit.
Refer to Attachment A Section C for HCPCS codes and limits.
Gait trainer initial criteria: a) Needs moderate to maximal support for walking due to impaired balance reactions or pelvic/trunk instability or has GMFCS score ≥3; and b) Able to initiate movement without caregiver assistance and movement is purposeful. PT/OT evaluation required and therapist must not be employed by equipment provider.age 0-20
Prior approval required for gait trainer with accessories.
AAC Devices - Initial
Augmentative and Alternative Communication (AAC) devices are covered when dedicated and medically necessary with extensive documentation and prior approval for speech‑generating devices.
AAC coverage criteria: a) Device determined medically necessary; b) Device is a dedicated communication device; c) Used solely by the beneficiary; d) Beneficiary has long‑term severe communication impairment. Prior approval required for speech‑generating devices, software, accessories and repairs; submit physician report, physician order itemizing components, and AAC evaluation by qualified SLP including language/oral motor status, therapeutic history, devices tried, justification, price quote, training plan, and statement of evaluator independence from vendor.
Dedicated device required; general‑purpose computing devices not modified for AAC are not covered.
Standers - Initial
Standers (ages 0–20) and accessories require prior approval with PT/OT evaluation documenting least‑cost appropriateness.
Stander coverage criteria: a) Requires moderate to maximal support for standing in the environment; b) Unable to stand or ambulate due to long‑term conditions and ambulation unlikely; c) Effective weight bearing cannot be achieved by other means; d) Stander has been tried and used safely; e) Environment accommodates stander; f) Beneficiary motivated to stand and caregiver able to carry out prescribed standing program; and g) PT/OT evaluation required showing least expensive appropriate device and alternatives considered with rationale. Certain simple components (knee/hip/chest supports, footplate, lateral supports, straps, tray) may be listed as not requiring separate justification.age 0-20
Therapist must not have financial relationship with supplier; prior approval required.
Bath and Toilet Aids
Bath and toilet aids include age‑specific pediatric provisions and require varying levels of documentation and prior approval.
Bath/Shower Chair or Tub Transfer Bench: Bath/shower chair covered when beneficiary cannot stand for bathing (no prior approval required). Tub transfer bench covered when beneficiary cannot safely get into/out of tub; heavy duty bench allowed for weight ≥250 lbs.
Raised toilet seat and commode: Raised toilet seat covered when beneficiary cannot get up from or down to a standard commode. Commode chair covered when beneficiary physically incapable of using standard toilet or cannot access bathroom. Extra wide/heavy duty allowed for weight ≥250 lbs.
Pediatric bath chairs: Covered ages 0–20 with prior approval when beneficiary cannot maintain sitting independently, needs recline/tilt, has poor head control, cannot be safely lifted due to size/weight, or requires positioning/support for safe bathing. Some safety accessories do not require prior approval.age 0-20
PT/OT LON required for prior approval of pediatric bath devices; therapist must be independent of supplier.
General eligibility for pediatric toilet supports/systems
General eligibility for pediatric toilet supports/systems (age and prior approval).
Age and prior approval: Beneficiary is age 0 through 20 years AND device requires prior approval; additional device‑specific criteria must be met per policy.age 0-20
See device subsections for further requirements.
Toilet Seat Reducer Ring
Toilet Seat Reducer Ring covered when any one of the following applies.
Reducer ring indication: Beneficiary (age 0–20) is too small to sit safely on regular commode opening but can safely sit with the reducer ring added.age 0-20
No prior approval required unless fee schedule indicates otherwise.
Lo-Back Toilet Support
Lo‑Back Toilet Support coverage when any one of specified conditions are present (age 0–20).
Lo‑Back indications: a) Cannot maintain balance while sitting on a commode and requires pelvic/trunk support to avoid loss of balance; b) Trunk weakness or tonal abnormalities; c) Poor protective reactions resulting in loss of balance and needs support for safety; d) Unable to sit on regular toilet seat without caregiver assistance to maintain balance.age 0-20
All accessories require prior approval and must be medically necessary.
Potty Trainer
Potty trainer covered when any one of the listed pediatric indications is met.
Potty trainer indications: a) Toileting/toilet training must occur outside a bathroom; b) Cannot be maintained in stable position while sitting on commode and requires additional support; c) Has deficits in balance, coordination, or function that prevent safe use of standard potty options.age 0-20
All accessories require prior approval and must be medically necessary.
Toileting System
Toileting system (pediatric) covered when any one of the functional requirements is met.
Toileting system indications: a) Cannot sit on a commode without complete caregiver support; b) Significant deficits in balance, coordination, or abnormalities in tone; c) Poor head or trunk control; or d) Will achieve independence in toileting with use of system.age 0-20
Therapist LON required for prior approval and accessories require prior approval.
This policy includes a dedicated "When the Procedure, Product, or Service Is Not Covered" section that lists both general and specific exclusions. General exclusions include items or services when the beneficiary does not meet eligibility (Section 2.0), does not meet the coverage criteria (Section 3.0), when the requested item would duplicate another provider's service, or when the procedure/product is experimental, investigational, or part of a clinical trial. Specific not-covered examples include devices and supplies provided for beneficiary or caregiver convenience, backup/duplication, items for inpatient settings where room and board would apply (unless a discharge plan is established), items covered by another agency, and hospice-related diagnoses as described in the policy.
Providers should consult the applicable equipment-specific sections for additional not-covered details (for example pediatric beds, wheelchairs, lifts, AAC devices) because the policy enumerates device-level noncoverage and contraindications in Section 4.2 and related subsections.
For Medicaid beneficiaries under age 21, the EPSDT special provision may override policy limits when an item is medically necessary to correct or ameliorate a condition identified by screening. EPSDT coverage does not apply to items that are unsafe, ineffective, experimental/investigational, or not medical in nature. Requests for EPSDT exceptions (items not listed in Attachment A Section C) should be submitted via NCTracks per the policy instructions.
The policy explicitly excludes items provided solely for convenience of the beneficiary or caregiver, and it does not cover backup/duplicate equipment placed at multiple locations. Equipment that is appropriately provided as part of inpatient room and board is not covered under this DME policy unless a discharge plan for provision outside the inpatient setting has been documented.
Examples of convenience-related noncoverage at the device level include powered lifts, which the policy states are considered caregiver convenience and are not covered, and backup wheelchairs (payment is allowed for only one wheelchair at a time), which are not medically necessary.
Pediatric hospital grade cribs, safety enclosures, and pediatric specialty beds are covered only when strict clinical criteria and documentation requirements are met. They are not considered medically necessary when furnished for caregiver convenience, behavior therapy, physical restraint, as a substitute for appropriate supervision, or when a regular bed would meet the beneficiary's needs.
Prior approval and the required supporting documentation (prescriber order, diagnosis justification, independent PT/OT letter of medical necessity, environmental suitability, and caregiver capacity) must be submitted for pediatric specialty beds; absent those justifications the items are noncovered.
The policy lists concrete examples of pediatric bed requests that will be denied as non‑medical: use for caregiver convenience, behavioral management or restraint, substitution for appropriate parental/caregiver supervision, or provision when an ordinary bed would satisfy the clinical need. These are treated as not medically necessary under the Specific Criteria Not Covered rules and will not be approved absent EPSDT exception for beneficiaries under 21.
Providers must include the required independent therapist evaluation or letter of medical necessity explaining why standard/hospital beds are inadequate and why less expensive options were considered and ruled out; failure to provide this documentation supports a noncoverage determination.
Air‑fluidized beds carry specific contraindications that make them noncovered for certain beneficiaries. Contraindications include coexisting pulmonary disease (where lack of firm back support impairs coughing), the need for wet soaks or moist dressings that are not protected with occlusive coverings, unwilling or unable caregivers to provide required care, inadequate structural support for the very heavy bed system, insufficient electrical capacity in the environment, or other documented contraindications.
Initial and renewal approvals for air‑fluidized beds are tightly time‑limited (typically one month at a time) and continued use requires ongoing documentation of wound healing and that alternative care measures are being optimized; absence of appropriate indications or presence of contraindications will result in denial.
The policy states that payment is allowed for only one wheelchair at a time; requests for backup or duplicate wheelchairs are not covered as not medically necessary. Providers should not submit claims for an additional wheelchair when an active, covered wheelchair is already in place for the beneficiary.
This single‑wheelchair rule applies across manual and power wheelchair categories unless otherwise specified in the policy (for replacement due to loss, theft, or irreparable damage follow the replacement documentation rules).
Hydraulic and mechanical patient lifts require prior approval and are covered only when the beneficiary's condition requires periodic movement to improve or arrest deterioration and the beneficiary or family cannot safely transfer the individual. Powered lifts, however, are explicitly listed as not covered because they are considered caregiver convenience and not medically necessary.
Augmentative and Alternative Communication (AAC) coverage is limited to dedicated communication devices that are used solely by the beneficiary. Unmodified general‑purpose computing devices (laptops, desktop computers, PDAs) that are not modified to run AAC software and are not dedicated to communication are not covered because they are not considered primarily medical in nature.
For standers and related accessories, the policy requires prior approval and therapist documentation to show that the selected device and each component are medically necessary and represent the least expensive appropriate option. Several common accessories (knee supports, hip supports, chest support, footplate/sandals, lateral supports, straps, trays) are listed as not requiring separate justification, but other accessory options are not covered.
Specifically, the policy notes that a mobile option, power lift option, or glider option for a stander are not covered accessories and will be denied if requested.
Evaluations performed by a physical or occupational therapist that support prior approval requests must be independent of the equipment supplier. The policy states that the therapist completing the letter of medical necessity or evaluation shall not be employed by or have a financial relationship with the medical equipment provider.
Providers must ensure the therapist documentation demonstrates medical necessity for each device component and includes the required rationale comparing less expensive alternatives; failure to use an independent evaluator may result in denial.
The policy contains a comprehensive Not Covered/Not Medically Necessary listing in Section 4.0 (and subsections) that enumerates both general exclusions and device‑specific noncoverage. General exclusions include ineligible beneficiaries, lack of coverage criteria, duplicate services, and experimental/clinical trial items. Device‑level noncoverage examples (e.g., powered lifts, unmodified general‑purpose computers used for AAC, backup wheelchairs) are summarized throughout the not‑covered subsections and the equipment‑specific sections.
When in doubt, refer to the device‑specific subsection and Section 4.2 to determine whether a requested item is explicitly excluded or requires additional documentation or EPSDT review for beneficiaries under 21.
Services, products, or procedures that are experimental, investigational, or part of a clinical trial are explicitly listed as not covered under the policy. Such items should not be billed to Medicaid under this DME coverage policy.
Coding and Attachments
Attachment A: coding referencesmixed
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Referenced HCPCS and DME fee scheduleHCPCS
see Attachment A Section C
HCPCS codes, established lifetime expectancies and quantity limitations for DME and supplies
Referenced HCPCS codes and fee scheduleHCPCS | mixed
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HCPCS/Procedure CodesHCPCS
Refer to Attachment A, Section C
List of HCPCS codes, established lifetime expectancies and quantity limitations for DME and supplies
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See Attachment A Section C
List of HCPCS codes, established lifetimes and quantity limits for DME and supplies
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Refer to Attachment A Section CHCPCS
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Rental determination threshold
Rental determination thresholdPhysician/PA/NP documents anticipated need — ≤ 6 months: item is rented; > 6 months: item may be rented or purchased (documentation required).
Purchase after rental restrictionOnce rental is initiated, subsequent prior approval requests to purchase that same item will be denied until accrued rental payments reach Medicaid allowable purchase price.
Capped rental contextCapped rental items follow the rental-then-purchase rule; accrued rental may convert item to beneficiary property at allowable purchase price.
Provider Actions and Prior Authorization
Prior Authorization
Obtain Prior Approval via CMN/PA and Submit Supporting Records
Prior approval is required for DME items as specified in the policy's Prior Approval Requirements and Attachment A; providers must submit the prior approval request and all supporting health records to the DHHS Utilization Review Contractor using the CMN/PA form. Prior approval is valid only for the time period approved on the CMN/PA; if a longer period is needed the provider must submit a new CMN/PA.
Submit prior approval request and all supporting health records to DHHS Utilization Review Contractor (5.2.1).
Use the CMN/PA form; prior approval is valid only for the approved time period and a new CMN/PA is required for longer need (5.1).
Medical necessity must be documented by the prescriber and may include a letter of medical necessity submitted with the CMN/PA (5.3).
Refer to Attachment A/fee schedule for items that require prior approval and for HCPCS code guidance (1.2, Attachment A references).
Note
TOC does not replace full Prior Authorization instructions
Medical Necessity — Device-Specific Criteria
Per-equipment medical necessity
Per‑equipment medical necessity and documentation subsections direct providers to device‑specific criteria and required submissions.
Per‑equipment subsections: Each equipment type has a dedicated subsection (e.g., 5.3.1 Hospital Beds; 5.3.2 Group 1 surfaces; 5.3.5 Manual Wheelchairs; 5.3.6 Power Wheelchairs) that lists medical necessity criteria and specific documentation/prior approval requirements.
Providers must follow the documentation and prior approval instructions in the applicable subsection and Attachment A/CMN/PA guidance.
Sections 5.9-5.11 referenced
Sections referenced in the table of contents indicate additional implementation and operational rules located later in the policy.
Referenced sections: Sections 5.9–5.11 and related sections address replacing medical equipment, changing suppliers, terminating rentals, and other operational topics that support medical necessity decisions and billing rules.
See the full policy sections for operational procedures.
Rental and Purchase Rules
Topic
Rule / Summary
Rental items generally
Sections describe assuring continuing need for rental items, delivery, servicing/repair, replacing equipment, changing suppliers, and terminating rentals; rental items are subject to CMN/PA time limits and record-keeping per policy sections on delivery and monitoring care.
TOC Entry
Implication for providers / rule
Terminating Rentals
Rental may be terminated by beneficiary, prescriber, or supplier; provider may reclaim equipment within 30 calendar days; capped rental items that have become beneficiary property cannot be reclaimed.
Changing Suppliers
When changing suppliers for rental items (other than oxygen), the new supplier must obtain a completed CMN/PA and a pick-up slip from the former supplier; allowable capped rental period credit transfers to new supplier; new prior approval number issued when required.
Replacing Medical Equipment
Policy includes procedures for replacing equipment and servicing/repair; rental equipment service is provided under rental arrangement; purchased equipment repairs handled under warranty or via PA with repair estimate when no warranty.
Item type
Capped rental / purchase rule
Capped rental / purchased equipment (general)
Item is rented if anticipated need documented ≤ 6 months; may be rented or purchased if anticipated need exceeds 6 months. Once rental is initiated, a subsequent request to purchase is denied until accrued rental payments reach Medicaid allowable purchase price; item becomes beneficiary property at that point.
Equipment class
Rental designation
Equipment requiring frequent and substantial servicing (examples include oxygen and oxygen delivery items)
These items are designated rental items.
Capped rental items
Provider rule / limitation
Capped rental items (policy reference)
Capped rental items have restrictions on length of rental; prior approval is valid for the approved time period on the CMN/PA; if longer need exists a new CMN/PA must be submitted. Rental credit transfers to a new supplier; provider may reclaim equipment within 30 days if rental terminated unless item became beneficiary property when total rental payments reached allowable purchase price.
Group 1 support surfaces
Rental / purchase rules
Group 1 pressure-reducing support surfaces
All Group 1 support surfaces must be rented when anticipated need is six months or less, except specific replacement pads which are purchase-only. May be rented or purchased when anticipated need exceeds six months (documented by prescriber).
Group 2 support surfaces
Rental rule
Group 2 pressure-reducing support surfaces
All Group 2 items are rented and only become beneficiary property when monthly rental payments reach the allowable purchase price; prior approval required for initial (up to 6 months) and renewals (up to 3 months).
Manual wheelchairs (rental)
Rule / duration
Manual wheelchairs
Prior approval for rental of a manual wheelchair is granted for a maximum of nine months when beneficiary meets basic manual wheelchair coverage criteria.
Electronics, chargers
Replacement / prior approval rules
Power wheelchair electronics and chargers
Electronic components covered when medically necessary. Replacement electronics require prior approval and are covered when part cannot be repaired, warranty expired, replacement extends wheelchair life, and replacement cost is less than a new comparable wheelchair. Initial battery/charger included with power wheelchair allowance; replacement chargers and many electronics require prior approval per fee schedule.
TENS units
Rental before purchase
TENS unit
Prior approval is required for TENS units. The TENS must be rented for 30 to 60 calendar days prior to requesting purchase.
Power wheelchair electronics / replacement parts
Rental / purchase / prior approval
Power wheelchair electronics and replacement parts
Replacement electronics require prior approval and meet criteria (non-repairable, warranty expired, cost-effective vs new wheelchair). Replacement parts are covered when replacing the part extends life and is less expensive than a new comparable wheelchair; follow prior approval rules on fee schedule.
AAC devices
Rental then purchase pathway
Augmentative and Alternative Communication (AAC) devices
Any AAC device requiring prior approval must be rented for a one-month evaluation period before Medicaid purchases the device. Rental fees for the one-month period apply to the purchase price; if rental unavailable, prior approval for purchase may be granted with documentation of recent effective use of the requested AAC.
Rental DME (including capped rental items)
Capped rental details / supplier rules
Rental DME and capped rentals
Capped rental rules: items rented per capped rental rules become beneficiary property when total rental payments reach Medicaid allowable purchase price; allowable rental period and accrued rental credit transfer to a new supplier when changing suppliers; providers may reclaim equipment within 30 days of rental termination unless item became beneficiary property.
Rental vs purchased equipment (mapping)
General rule / service & repair
Rental versus purchase mapping (general DME)
Items are categorized: inexpensive/routinely purchased (purchase), capped rental (rental with purchase when accrued rental = allowable purchase price), items requiring frequent substantial servicing (rental), and individually priced items reviewed case-by-case. Service and repair: rental equipment service included in rental; purchased equipment covered under warranty or via PA with repair estimate when no warranty.
general DME (replacement mapping)
General DME replacement guidanceReplacing medical equipment considered when repair is not cost-effective and item is out of warranty; prior approval required for replacement before expected life expectancy with explanation on CMN/PA.
Documentation for loss/theft/damageProvide supporting documentation for loss/theft/destruction (social worker letter, police report, fire report) when requesting replacement.
Refer to Attachment ARefer to Attachment A, Section C for procedure codes, lifetime expectancies and quantity limits for replacement decisions.
Replacement and Repair Rules
Beneficiary-owned equipment
Beneficiary-owned equipment replacementService and repair of medical equipment owned by a beneficiary is covered over the useful life of the item; replacement considered when repair is no longer cost-effective and item is out of warranty.
Refer to servicing/replacement sectionSee Subsection 5.8 (Servicing and Repairing Medical Equipment) and 5.9 (Replacing Medical Equipment) for required documentation and rules.
Attachment A linkageAttachment A, Section C lists procedure codes and lifetimes that govern replacement decisions and prior approval requirements.
Hospital bed mattress or side rails replacement
Mattress/side rails replacement conditionReplacement of a hospital bed mattress or side rails is covered when worn out or broken and continued use of the approved beneficiary-owned hospital bed is medically necessary.
Documentation and Claims
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Claims, Coding, and Submission Notes
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Background
Scope: This Durable Medical Equipment (DME) policy governs coverage, prior approval, documentation, rental/purchase rules and replacement of a wide range of DME and related supplies for Clear Health Alliance beneficiaries. Covered equipment categories include hospital and pediatric beds, pressure‑reducing support surfaces, manual and power wheelchairs and accessories, activity/positioning chairs, patient lifts, pneumatic compressors, TENS, osteogenesis stimulators, CPM devices, gait trainers, AAC devices, standers, and bath/toilet aids.
The policy establishes general coverage criteria (items must be ordered by an authorized prescriber, be medically necessary to maintain or improve function in a noninstitutional setting, and be supported by a face‑to‑face encounter within six months) and references Attachment A Section C for HCPCS codes, lifetime expectancies, and quantity limits. Prior approval is required for many categories as specified in the policy.
Definitions
Durable Medical Equipment (definition reference)
Durable Medical Equipment (DME) definitionDME is equipment primarily used for a medical purpose, generally not useful in the absence of a disability, can withstand repeated use, and can be reusable or removable.
Supplies definitionSupplies are consumable or disposable health-care items that cannot withstand repeated use by more than one individual and are required to address a medical disability, illness, or injury.
Ordering and use criteriaDME items must be ordered by an authorized prescriber, medically necessary to maintain or improve medical/functional level, appropriate for noninstitutional use, with a face-to-face encounter within six months and annual review.
Durable Medical Equipment definition (expanded)
Expanded DME definition and ordering requirementsDME is ordered by physician/PA/NP, medically necessary for medical/functional needs, appropriate for noninstitutional settings; face-to-face encounter within 6 months and annual review required.
Not Covered / Exclusions
The policy includes both general not‑covered rules and many device‑specific noncoverage statements. General exclusions (Section 4.1) include lack of eligibility, failure to meet Section 3.0 criteria, duplication of another provider's service, and items that are experimental or investigational. Specific noncoverage rules (Section 4.2) enumerate categories such as items for convenience, backup/duplication, items covered under inpatient room and board, items covered by another agency, and hospice‑related items.
Examples of specific not‑covered items scattered through the equipment sections include: powered patient lifts (considered caregiver convenience), unmodified general‑purpose computers used for AAC (not covered because not dedicated to communication), and backup wheelchairs (payment for only one wheelchair at a time). These lists should be consulted when preparing prior approval requests or determining medical necessity for billing.
The policy explicitly excludes items supplied for convenience or as backups/duplicates and excludes equipment already covered as part of inpatient room and board unless a discharge plan to a residential setting exists. Examples include powered lifts (not covered) and backup wheelchairs (not covered because payment is made for only one wheelchair at a time).
When items are furnished at discharge from an inpatient setting, providers must follow the policy's provisions for discharge delivery and documentation; otherwise, inpatient room and board‑covered equipment is not reimbursable as DME under this policy.
This block is a placeholder for additional not‑covered examples and cross‑references; see Section 4.0 and 4.2 in the policy for the full enumerated lists of both general and device‑specific noncoverage criteria.
Providers should always check the specific equipment subsection and the Not Covered section before submitting claims to ensure requested items are not explicitly excluded.
Revision History
Policy Summary
Payerclearhealthalliance
PolicyDurable Medical Equipment and Supplies Coverage Criteria
Policy CodePolicy Policy 5A-1
Change TypeNo material change
Effective Date
Next Review Date
Key ActionSubmit completed CMN/PA with required clinical documentation and therapist letters of medical necessity for items requiring prior approval.
1) Meets semi‑electric criteria; and 2) Electric variable bed height is necessary for ambulation/transfer or to complete ADLs.
Subsection 5.3.1.d
Oversized Hospital Bed and Mattress: 1) Meets medical necessity for comparable standard size equipment and demonstrates need for oversized equipment; 2) Height, weight and body measurements taken in appropriate position are included and meet HCPCS weight requirements; 3) Equipment dimensions and manufacturer's weight capacity are submitted.
Subsection 5.3.1.e
Pediatric beds/cribs/safety enclosures: Order from authorized prescriber documenting appropriateness; or condition requires head/foot adjustments or special attachments not feasible on ordinary bed/crib; plus PT/OT evaluation or LON and environmental/caregiver capacity documentation for pediatric specialty beds.
Subsection 5.3.1 Pediatric Beds
Covered when height adjustments are needed for medically necessary activities or to allow independent transfers into/out of the chair.
Therapist documentation: A letter of medical necessity from an independent PT/OT is required for prior approval; therapist must demonstrate the requested chair and components are the least expensive appropriate device and describe alternatives considered and rationale.
Therapist must not be employed by or have financial relationship with supplier.
radiographs separated by >=90 days
Prior approval required.
Bath support and bath lift: Bath support prior approval required when minimal to moderate assistance needed to maintain upright seated position, extensor thrusting, or abnormal tone. Bath lift prior approval required when moderate to maximal assistance needed for tub transfers, insufficient balance/head/trunk control, or beneficiary can operate controls but cannot transfer safely.
Shower/Commode and Tilt/Recline Chairs: Shower/commode chair prior approval required when unable to stand for bathing, cannot be safely assisted into/out of tub, lacks balance/trunk support, or lacks access to tub. Tilt/recline shower/commode prior approval required for extensive weakness/contractures, total assistance transfers, inability to sit upright, need for tilted position, or continuous pressure relief.
All accessories require medical justification.
Pediatric bath shower transfer system: Prior approval required when beneficiary requires maximal assistance to sit, has extensive weakness/contractures/abnormal tone requiring full body support, requires total assistance for transfers/bathing, or must use a bathtub for bathing. PT/OT LON required and therapist must not have financial relationship with provider.age 0-20
Pediatric toilet supports/systems: Require prior approval and are covered for ages 0–20 when beneficiary is toilet trained or capable of being toilet trained within six months and able to participate in a toileting program. A therapist LON and completed CMN/PA required with documentation that device and components are least expensive appropriate option and alternatives considered.age 0-20
Prior approval required.
Toilet Seat Reducer Ring: Covered for ages 0–20 when beneficiary is too small to sit safely on a regular commode but can safely sit with the reducer ring added.age 0-20
CMN/PA physical measurements requirement
Required physical measurements on CMN/PAInclude beneficiary height, weight, and body measurements taken in the appropriate position (e.g., shoulder-to-shoulder or hip-to-hip measured in supine) to meet HCPCS weight/capacity requirements.
Equipment dimensions and manufacturer capacitySubmit dimensions of the requested equipment and the manufacturer's specified weight capacity on the CMN/PA form.
Use for oversized beds and wheelchairsMeasurements required when requesting oversized hospital beds, oversized manual wheelchairs, heavy-duty walkers/canes, or other heavy-duty equipment.
Weight thresholds for wheelchairs
Heavy-duty thresholdBeneficiary weight > 250 pounds defines a heavy-duty manual wheelchair or heavy-duty cane/crutch; prior approval required for heavy-duty items.
Extra heavy-duty thresholdBeneficiary weight > 300 pounds defines an extra heavy-duty manual wheelchair (and heavy-duty power wheelchair threshold is > 300 lbs).
Oversized thresholdOversized manual wheelchairs are for weights greater than 451 pounds — prior approval required.
Rental vs purchase threshold
Rent vs purchase ruleAnticipated need ≤ 6 months: rent; anticipated need > 6 months: may rent or purchase if documented by physician/PA/NP.
Group 1 support surfaces exceptionGroup 1 support surfaces must be rented when anticipated need ≤ 6 months; certain replacement pads are purchase-only.
Oversized manual wheelchairOversized manual wheelchairs cover beneficiaries > 451 pounds; include height/weight/body measurements and equipment dimensions on PA request.
Heavy-duty power wheelchairHeavy-duty power wheelchairs are for beneficiaries who weigh more than 300 pounds; prior approval requires height/weight/body measurements and manufacturer's weight capacity.
Documentation requirementSubmit dimensions and manufacturer's specified weight capacity with prior approval for heavy-duty or oversized wheelchairs.
minimum daily wheelchair use
Minimum daily use for power seatingBeneficiary must spend a minimum of six hours per day in the wheelchair to meet criteria for power seating systems (tilt/recline).
Power seating justificationPower seating (tilt/recline) also requires inability to reposition, risk to skin integrity, or other listed clinical indications.
Prior approval requiredPower seating systems require prior approval and supporting clinical documentation.
heavy duty weight threshold
Heavy-duty weight thresholdBeneficiary weight > 250 pounds is the threshold used to define heavy-duty canes/crutches, heavy duty transfer benches, and some heavy-duty commodes/transfer devices.
Document measurementsCMN/PA must include beneficiary height, weight, body measurements and equipment dimensions for heavy-duty items.
ApplicabilityThreshold applies to heavy-duty walkers, transfer benches, commode chairs and related bath/toilet aids where specified.
non-union radiographic separation
Non-union radiographic requirementNon-union requires at least two sets of radiographs separated by a minimum of 90 calendar days showing no clinically significant evidence of healing, with written physician interpretation.
Exclusions by siteFractures of the skull or vertebrae and tumor-related fractures are excluded from ultrasonic stimulator coverage.
Prior approval requiredUltrasonic osteogenesis stimulator coverage requires prior approval and the specified radiographic documentation.
weight limit for heavy duty equipment
Weight limit for heavy duty equipment>= 250 pounds is used as the threshold for heavy-duty transfer benches, commode chairs, and other heavy-duty bath/toilet equipment.
CMN/PA measurements requiredInclude beneficiary height, weight, body measurements and manufacturer's specified weight capacity on the CMN/PA form for heavy-duty items.
Prior approval for some itemsSome heavy-duty items require prior approval; check device-specific sections for requirements.
The Table of Contents in this extract references rental, supplier, and billing sections but does not include the detailed prior authorization procedures; providers must follow the full Prior Approval Requirements and Attachment instructions elsewhere in the policy.
TOC entries alone do not constitute authorization instructions—see sections 5.1–5.3, Attachment A, and Attachment D for full PA procedures.
Note
Full Prior Authorization details are in main sections and attachments
This excerpt does not contain the full prior authorization rules; providers must consult the detailed sections (5.2.1 General, device-specific subsections, and Attachments A–D) for specific PA criteria and submission steps.
Refer to 5.2.1 and device-specific subsections (e.g., 5.3.x) and Attachment D for unlisted item requests and adult procedures.
Note
No PA specifics in TOC extract — use Sections 5.2 and Attachments
The Table of Contents extract does not list item-level PA specifics; providers must use the policy sections (5.2.1, 5.3.x) and Attachment A to determine which items require prior approval and what documentation to submit.
Attachment A (Claims-Related Information) and Section 5.2 identify PA items and claims submission details (see Attachment A Section C for HCPCS codes).
Note
TOC entries alone do not list PA requirements
No explicit prior authorization requirements are specified in the Table of Contents excerpts shown; follow the 'Prior Approval Requirements' (5.2) and device-specific documentation sections for actionable PA steps.
Submit required documentation per 5.2.1 and device-specific 5.3 subsections when PA is indicated.
Prior Authorization
Check Attachment A Section C for codes that require PA
Attachment A (Claims-Related Information) and Attachment C/D contain the lists of procedure codes and the attachments identify which HCPCS/procedure codes require prior approval; providers must consult Attachment A Section C for affected codes.
Refer to Attachment A, Section C: Procedure Code(s) for HCPCS codes and which items require prior approval.
For unlisted adult items follow Attachment D procedures; for beneficiaries under 21 request an EPSDT review via NCTracks (1.2, Attachment D).
Billing Rule
Use Attachment A for claims/coding guidance
Claims, modifier, billing units, place-of-service, and other coding/billing guidance are located in Attachment A; providers must use those headings and follow Attachment A when submitting claims to avoid processing issues.
Use Attachment A headings (Claim Type; ICD-10-CM/PCS; Procedure Code(s); Modifiers; Billing Units; Place of Service; Co-payments; Reimbursement) when preparing claims.
Attachment C provides instructions for completing DME claims (page references in TOC).
Note
Follow attachments and main sections for PA procedures
The Table of Contents points to attachments and implementation sections where prior authorization rules are detailed; providers must follow those referenced sections rather than relying on the TOC alone.
See Attachments A–D and sections 5.1–5.3 for operational PA rules and submission portals (NCTracks).
Prior Authorization
Prior approval required for items not listed in Attachment A Section C
Items not listed in Attachment A Section C or the DME fee schedule require prior approval review of medical necessity; for beneficiaries under age 21 request an EPSDT review via NCTracks, and for adults submit through NCTracks per Attachment D instructions.
Unlisted items require prior approval/medical necessity review (refer to Attachment D for adults).
EPSDT review via NCTracks is required for beneficiaries under 21 for items not listed.
Prior Authorization
Submit PA for items identified on the DME fee schedule
Certain items identified on the Durable Medical Equipment Fee Schedule require prior approval; providers must submit the prior approval request and supporting medical records to the DHHS Utilization Review Contractor and follow the CMN/PA guidance.
Refer to the DME fee schedule for items that require PA and the valid time period noted on the CMN/PA (5.1).
If longer duration is needed, submit a new CMN/PA.
Prior Authorization
Prior approval required for hospital and pediatric beds
All hospital beds, pediatric cribs, pediatric hospital beds, safety enclosures, pediatric specialty beds and related supplies require prior approval; submit CMN/PA and the prescriber's order and supporting documentation as specified in the hospital/pediatric bed sections.
Include prescriber order documenting appropriateness and any required therapist evaluation or letter of medical necessity for pediatric specialty beds (5.3.1, pediatric bed criteria).
For oversized beds include beneficiary height/weight/body measurements and equipment dimensions on the CMN/PA (5.3.1.e).
Prior Authorization
PA required for key support surfaces and all wheelchairs
Prior approval is required for pediatric specialty beds, Group 2 and Group 3 support surfaces, all manual and power wheelchairs (including transport chairs), and oversized wheelchairs; requests must include the documentation and criteria specified in the respective policy subsections.
Attach device-specific documentation (e.g., PT/OT evaluation, face-to-face physician exam, MSRP quote) per the relevant 5.3 subsection.
Group 2 initial approvals limited to 6 months; Group 3 (air-fluidized) initial/renewals typically limited to 1 month (5.3.3–5.3.4).
Prior Authorization
PA required for oversized, power wheelchairs, heavy-duty chairs, electronics
Prior approval is required for oversized manual wheelchairs (>451 lbs), all power wheelchairs, heavy-duty power wheelchairs (>300 lbs), many batteries (Group 27), power seating systems and most replacement electronics; include the specified measurements, face-to-face exam, environmental assessment, and MSRP in PA submissions.
Oversized manual wheelchair requests must include beneficiary height/weight/body measurements and equipment dimensions/weight capacity (5.3.5/5.3.6/5.3.8).
Power wheelchair PA requires face-to-face physician exam note, onsite environmental assessment with measurements, and MSRP quote (5.3.6).
Group 27 batteries and most replacement electronics require PA (Batteries, Electronics sections).
Prior Authorization
PA needed for power seating systems — meet all specified clinical criteria
Power seating systems (tilt, recline, combination) require prior approval and are covered only when all clinical criteria are met (positioning need, deformity/tone issues, inability to reposition, skin/respiratory/cardiac benefit, ≥6 hours/day wheelchair use, and lack of caregiver to perform manual function).
Document minimum daily wheelchair use of six hours and clinical justification for each seating feature (5.3.8 Power Seating Systems).
Prior Authorization
Obtain PA for most electronics/replacement electronics
Most electronics and replacement electronics require prior approval; check the DME fee schedule (items marked with an asterisk) and include justification that the replaced part cannot be repaired, warranty expired, replacement extends life, and cost is less than a new comparable wheelchair.
Provide documentation that repair is not possible, warranty expired, and replacement is cost-effective versus a new wheelchair when requesting PA for electronics (Electronics section).
Prior Authorization
PA required for hydraulic/mechanical patient lifts (powered lifts not covered)
Hydraulic or mechanical patient lifts require prior approval and are covered when periodic movement is necessary and the beneficiary or family cannot safely transfer the beneficiary; note that powered lifts are not covered.
Submit CMN/PA and documentation showing need for periodic movement and inability of caregiver/family to transfer safely (5.3.9).
Powered lifts are explicitly not covered as caregiver convenience.
Prior Authorization
PA and CMN/PA Block 24 required for pneumatic compression devices
All pneumatic compressors and appliances require prior approval; Block 24 of the CMN/PA form must be checked for pneumatic compression devices and documentation must show less intensive treatments were tried and found inadequate.
Document prior conservative therapies (elevation, custom compression garments) and show physician oversight/treatment plan; ensure Block 24 is checked on CMN/PA (5.3.10).
Prior Authorization
PA and rental requirement for TENS; include detailed pain history and trial info
TENS units require prior approval and must be rented for 30–60 days prior to requesting purchase; include a detailed pain history, prior treatments tried, improved ADL tolerance statement, pain scale and body map with the PA submission.
Attach diagnosis, onset/duration, pain locations, prognosis, treatments tried, statement of improved ADL tolerance, pain scale/body map, and evidence of rental trial (30–60 days) with PA request (5.3.11).
Prior Authorization
PA required for osteogenesis stimulators with specified radiographic/time criteria
All osteogenesis stimulators require prior approval; submit radiographic/time-based evidence per the policy (e.g., two radiograph sets separated by ≥90 days for long-bone non-union) and documentation meeting the specified diagnostic time thresholds.
For long-bone non-union, submit two radiograph sets ≥90 days apart with written interpretation showing no healing; note minimum time thresholds for non-union and failed fusion (5.3.12).
Prior Authorization
PA and timing limits for CPM devices (start within 2 days; 3-week limit)
Continuous passive motion (knee) devices require prior approval; use must begin within two days post-total knee replacement and is limited to a three-week period, and Block 24 on the CMN/PA must be checked.
Document start of use within two days post-op and limit use to three weeks; ensure Block 24 is checked on CMN/PA (5.3.13).
Prior Authorization
PA required for gait trainers, AAC, standers, pediatric bath systems and related DME
Prior approval is required for gait trainers with accessories, AAC devices and software, standers and accessories, pediatric bath chairs and transfer systems, shower/commode and tilt chairs, pediatric toilet supports/systems and other specific DME listed; follow CMN/PA instructions and submit required evaluator reports and itemized orders.
For gait trainers and standers include PT/OT evaluations documenting device-specific clinical criteria and independence from the equipment supplier.
For AAC include physician report, physician order itemizing components, and a qualified SLP evaluation per policy (5.3.16, 237–238).
Prior Authorization
PA and documentation required for pediatric toilet supports/systems
Pediatric toilet supports and toileting systems require prior approval; providers must submit a completed CMN/PA plus a therapist letter of medical necessity and supporting documentation demonstrating the beneficiary is toilet-trained or can be trained within six months and that the device is the least expensive appropriate option.
Include PT/OT LON demonstrating medical necessity, description of less expensive alternatives considered and reasons they are inappropriate, and completed CMN/PA.
For PA items delivered at discharge, submit prescriber's order and admission H&P via NCTracks portal; for non-PA items keep documentation on file (5.3.19).
Billing Rule
Document anticipated need — rental-before-purchase and capped rental rule
If anticipated need is six months or less the item is rented; if anticipated need exceeds six months the item may be purchased, but once rental has been initiated a subsequent request to purchase that capped rental item will be denied until accrued rental payments reach the Medicaid allowable purchase price.
Provider must document anticipated need duration (physician/PA/NP) on CMN/PA to justify rental vs purchase (1.2, 5.1).
Capped rental accrued payments transfer toward purchase price; purchase denied after rental initiation until price reached.
Documentation Required
Document why less-costly beds/options are inadequate
When requesting specialty beds or accessories providers must explain why a regular bed or hospital bed with rails and rail pads does not meet the beneficiary's needs and document consideration of less expensive specialty beds and why they were ruled out.
PT/OT evaluation or LON must include explanation why ordinary beds are insufficient and list less expensive alternatives considered with rationale (pediatric bed criteria 5.3.1).
Step Therapy
Require documented conservative treatment before Group 2/3 support surfaces
Group 2 and Group 3 support surfaces require prior conservative treatment attempts prior to approval: Group 1 support surface use and a comprehensive ulcer treatment program must be documented before Group 2; Group 3 requires comprehensive conservative measures and monthly physician re-evaluation.
Document prior use of an appropriate Group 1 support surface and a comprehensive ulcer treatment program of at least one month for Group 2 initial approval (5.3.3).
For Group 3 (air-fluidized) document ≥1 month of conservative program without improvement, caregiver availability, and physician monthly re-evaluation (5.3.4).
Documentation Required
Document why conservative mobility options are insufficient before PA for power wheelchair
Providers must document why a cane, walker, or manual wheelchair is insufficient before approving a power wheelchair; the face-to-face physician exam and supplemental clinical records must explicitly compare alternatives and justify power wheelchair need.
Include assessment showing limitations despite cane/walker/manual wheelchair and how power wheelchair will improve MRADLs (Standard Power Wheelchair criteria).
Provide face-to-face physician exam narrative and environmental assessment to support PA for power wheelchair (5.3.6).
Step Therapy
Require prior conservative therapies before PA for pneumatic compression
Pneumatic compression devices are covered only after less intensive treatments (elevation, custom compression garments) have been tried and found inadequate; prior approval with physician oversight and treatment plan is required.
Document prior standard treatments and physician-directed treatment plan including pressure, frequency, duration, and monitoring; ensure Block 24 on CMN/PA is checked (5.3.10).
Documentation Required
Document least-cost alternatives and therapist LON for standers
For standers, the CMN/PA submission must show the selected stander and each component is the least expensive appropriate device, include a description of less expensive alternatives considered, and provide a therapist evaluation documenting device-specific criteria.
Include PT/OT evaluation and documentation of least-expensive-appropriate-device rationale; list accessories and justify medical necessity for each (5.3.17).
Therapist must not be employed by or have a financial relationship with the equipment provider.
Documentation Required
Include rationale for least expensive alternative in PA documentation
The documentation for prior approval requests must describe other less expensive devices considered and explain why they were inappropriate for the beneficiary; this justification is required across multiple device categories.
Provide explicit comparison of alternatives and clinical rationale for choosing the requested device; include MSRP/price quote and measurements where applicable.
Documentation Required
Document medical necessity for every DME item (prescriber LON required)
Providers must document medical necessity for every item provided regardless of PA requirements; a prescriber-signed letter of medical necessity may be submitted with the CMN/PA and is required to support the request.
Letter of medical necessity from the physician/PA/NP must accompany CMN/PA for each item, detailing how criteria are met (5.3).
Prior Authorization
Document anticipated need and submit PA/EPSDT via NCTracks
Submit prior approval or EPSDT review through NCTracks as applicable; the prescribing physician/PA/NP must document anticipated need duration to justify rental versus purchase.
For beneficiaries under 21 request an EPSDT review via NCTracks for unlisted items; for adults follow Attachment D and NCTracks procedures.
Document anticipated need (≤6 months rent; >6 months may purchase) on CMN/PA (1.2).
Documentation Required
Include prescriber LON and independent therapist/SLP evaluations as required
A Letter of Medical Necessity signed by the prescriber must be submitted for every item and documentation must support medical necessity; device-specific evaluator reports (PT/OT/SLP) are required where noted and must be independent of the supplier.
PT/OT letters required for activity/positioning chairs, gait trainers, standers, pediatric bath systems, and toileting systems; SLP evaluation required for AAC devices (5.3 subsections).
Evaluators must not be employed by or have financial relationships with the DME provider.
Documentation Required
Include precise body measurements and equipment specs for oversized beds
For oversized hospital beds include beneficiary height, weight, and body measurements taken in the appropriate position, equipment dimensions, and the manufacturer's specified weight capacity on the CMN/PA.
Measurements must be appropriate to the requested equipment (e.g., shoulder-to-shoulder or hip-to-hip in supine for hospital beds) and submitted with CMN/PA (5.3.1.e).
Documentation Required
Submit order, diagnosis, and independent PT/OT LON for pediatric beds
For pediatric beds include the prescriber's order, diagnosis supporting need for specialized features, and an independent PT/OT evaluation or letter of medical necessity detailing how each feature is necessary and why regular/hospital beds are inadequate; also include environment and caregiver capability documentation.
PT/OT evaluation must explain why less expensive specialty beds were considered and ruled out; therapist must not be financially tied to supplier (5.3.1 pediatric beds).
Documentation Required
Include prescriber order plus device-specific evaluations, measurements, and MSRP with PA
Required documentation for prior approval items includes the prescriber's order and device-specific supporting documentation (e.g., PT/OT evaluation, face-to-face physician exam, MSRP quote, beneficiary measurements) as specified in the relevant 5.3 subsection.
Power wheelchairs: face-to-face physician exam note, onsite environmental assessment, and MSRP quote (5.3.6).
Manual/pediatric/oversized wheelchairs: PT/OT clinical evaluation and MSRP quote; supplier-generated physician forms are not acceptable (5.3.5, 197, 198).
Documentation Required
Record beneficiary weight and measurements on CMN/PA for heavy-duty items
Beneficiary weight must be stated on the CMN/PA for heavy‑duty trapeze bars and for heavy-duty/oversized wheelchair equipment include height/weight/body measurements and manufacturer's weight capacity in PA submissions.
State beneficiary weight on CMN/PA for heavy-duty trapeze; include full body measures and equipment specs for heavy-duty/oversized wheelchairs (5.3.2/5.3.5/5.3.6).
Documentation Required
Include face-to-face physician exam, environmental assessment, and MSRP for power/heavy-duty wheelchairs
Prior approval requests for power and heavy-duty wheelchairs must include a face-to-face physician exam note documenting strength, mobility, functional deficits and MRADL need; an onsite environmental assessment with measurements; and a manufacturer's MSRP quote with detailed item descriptions.
Face-to-face exam must be an in-person physician visit documented in a detailed narrative indicating mobility examination as the major reason for the visit (5.3.6).
Onsite environmental assessment must verify doorway widths, thresholds, and household surfaces (5.3.6).
Documentation Required
Require independent therapist LON and detailed evaluation with CMN/PA
Therapist documentation and CMN/PA requirements: a letter of medical necessity from an independent physical or occupational therapist is required for activity/positioning chairs, gait trainers, pediatric bath systems, and other devices; the therapist must not be employed by or financially related to the equipment provider.
Therapist must document device necessity, that requested components are the least expensive appropriate option, and list alternatives considered with rationale (5.3.22, 5.3.16, 5.3.14/5.3.17).
Documentation Required
Submit CMN/PA plus physician report and qualified SLP evaluation for AAC
For AAC prior approval submit the CMN/PA with a physician's report, a physician's order itemizing components, and an AAC evaluation by a qualified speech-language pathologist documenting language/oral-motor status, therapeutic history, prior devices tried, device specifics and price quote, need ≥12 months, training plan, and evaluator independence.
SLP evaluation must meet licensure/competency criteria and include device manufacturer, catalog number, product description, accessories, and price quote (5.3.16–5.3.18).
Documentation Required
Submit CMN/PA and PT/OT evaluation for standers and pediatric bath systems
Stander and pediatric bath system prior approval requires a completed CMN/PA and supporting PT/OT evaluation that documents medical necessity for the device and each accessory, shows the device is the least expensive appropriate option, and lists less expensive alternatives with rationale.
PT/OT evaluation must demonstrate clinical criteria (e.g., moderate-maximal support, safe prior use, environment suitability) and independence from the equipment supplier (5.3.17, 251).
Documentation Required
Provide PT/OT evaluation meeting gait trainer criteria and independence requirements
Gait trainers require a PT/OT evaluation documenting specified clinical criteria (moderate to maximal support needs, ability to initiate movement, GMFCS ≥3 when applicable); the evaluator must not be employed by the equipment provider and must itemize components and justification.
Include therapist documentation that the beneficiary can initiate movement without caregiver assistance and that use is purposeful, and list accessories with medical necessity (5.3.15/5.3.16).
Documentation Required
Submit completed CMN/PA, therapist LON, and least-cost justification for PA
For prior approval the DME provider must submit a completed CMN/PA form, a letter of medical necessity from the beneficiary's physical or occupational therapist (therapist must not be employed by or have a financial relationship with the supplier), and documentation demonstrating device necessity and that it is the least expensive appropriate option.
For PA items delivered at discharge, submit prescriber's order and admission history and physical electronically via NCTracks; for non-PA items retain documentation on file (5.3.19).
Denial Risk
Risk of denial if required prior approval is not obtained
Lacking required prior approval may result in denial; providers must obtain PA when required and submit complete supporting documentation to avoid denials for missing PA.
Verify whether the item requires PA via Attachment A/fee schedule before delivery or claim submission.
Submit complete CMN/PA and supporting health records to DHHS Utilization Review Contractor to reduce risk of denial.
Denial Risk
No explicit authorization/denial triggers in TOC extract — consult full sections
This TOC extract does not include explicit authorization or denial triggers; providers should consult the full policy sections referenced (Sections 4.0–5.3 and attachments) where denial criteria and triggers are defined.
Do not assume absence of triggers in the TOC means none exist; review Section 4.0 (Not Covered) and device-specific subsections for explicit denial conditions.
No explicit denial triggers are present in this excerpt of the Table of Contents; providers must review Section 4.0 (When Not Covered) and the device-specific criteria in Section 5.3 for denial reasons tied to coverage criteria.
Common denial reasons include failure to meet Section 3.0 coverage criteria, lack of eligibility, duplicate services, or experimental/investigational status (4.1).
Denial Risk
Risk of claim denial for incomplete/incorrect claims—use Attachment A/C
Claims submitted with incomplete or incorrect claims-related information (incorrect procedure codes, missing modifiers, wrong billing units, incorrect place of service, or missing claim type) may be denied or cause processing delays; use Attachment A and Attachment C guidance when preparing claims.
Follow Attachment A headings and Attachment C instructions for completing DME claims to minimize claim denials (Attachment A: A–H and Attachment C).
Confirm HCPCS codes in Attachment A Section C and apply required modifiers/billing units per Attachment A.
Billing Rule
Follow Attachment A coding/procedures to avoid claim denials
Claims submitted outside the procedures, coding, and documentation specified in Attachment A may be denied; providers must follow Attachment A for Procedure Code(s), Modifiers, Billing Units, Place of Service, and Reimbursement rules.
Use the durable medical equipment fee schedule and Attachment A Section C for correct HCPCS coding and quantity/lifetime limits.
Denial Risk
No denial triggers in TOC — see Section 4.0 and device subsections
This Table of Contents excerpt does not specify denial triggers; detailed denial conditions appear in Section 4.0 and device-specific subsections—providers should consult those sections for explicit denial criteria.
Section 4.0 lists general not-covered reasons (ineligibility, not meeting coverage criteria, duplication, experimental/investigational) that commonly trigger denials.
Denial Risk
Purchase requests denied after rental initiation for capped rental items
A purchase request for a capped rental item will be denied if rental has already been initiated on that item; purchase may occur only when accrued rental payments reach the Medicaid allowable purchase price.
Document anticipated need on CMN/PA before initiating rental to preserve purchase options when appropriate (1.2, 5.1).
Claims may be denied when the beneficiary does not meet eligibility, does not meet the coverage criteria in Section 3.0, the service duplicates another provider's service, or the procedure/product is experimental/investigational.
Verify beneficiary eligibility and that documentation satisfies Section 3.0 coverage criteria before submitting PA or claims (4.1).
Denial Risk
Air-fluidized bed denial triggers (contraindications and requirements)
Air-fluidized beds have specific contraindications; they are denied as not medically necessary for beneficiaries with coexisting pulmonary disease, when wet/moist dressings are used without protection, when caregiver is unwilling/unable to provide required care, when structural or electrical support is inadequate, or other listed contraindications.
Initial PA for air-fluidized beds is limited to one month and renewals to one month; continued use requires documentation of healing and ongoing medical necessity (5.3.4, notes).
Denial Risk
Pediatric bed non-coverage triggers — caregiver convenience/behavior/restraint
Pediatric beds and related specialty beds are not medically necessary when used for caregiver convenience, behavior therapy, physical restraint, as a substitute for appropriate supervision, or when a regular bed meets the beneficiary's needs; such uses risk denial.
Ensure documentation clearly shows medical necessity and that less expensive options are insufficient to avoid denials for pediatric beds (5.3.1 pediatric criteria).
Denial Risk
Power wheelchair non-coverage for reversible conditions with need <3 months
A power wheelchair is not medically necessary when the underlying condition is reversible and the length of need is less than three months; such requests should not be approved and will be denied when criteria are not met.
Document expected duration of need and reversibility of condition; short-term reversible needs (<3 months) do not meet power wheelchair criteria (5.3.6).
Denial Risk
Denial risk for canes/crutches when medical necessity criteria are not met
Canes or crutches will be denied if the mobility criteria are not met (i.e., no significant impairment in one or more MRADLs, inability to safely use the device, or functional deficit not resolved by the device); ensure documentation meets the MRADL definition and criteria.
MRADLs are defined as toileting, feeding, dressing, grooming, and bathing; document how the device will address these deficits (5.3.14).
Medical necessity and EPSDT exceptions
Medical necessity determinations follow the general definitions and EPSDT exceptions where applicable.
General medical necessity: Items must be medically necessary to address beneficiary's disability, illness, or injury; unlisted items require prior approval with supporting medical necessity rationale; EPSDT allows coverage for beneficiaries <21 when medically necessary to correct or ameliorate a condition identified through screening, provided the service is not unsafe, ineffective, or experimental.age‑dependent
Refer to Subsections 3.1 and 2.2.1 for definitions and EPSDT rules.
Bed-specific medical necessity
Bed‑specific medical necessity criteria summarize the conditions required for coverage and prior approval.
Fixed height bed: Requires head/foot adjustments not feasible in ordinary bed; or special attachments not usable on ordinary bed.
See Subsection 5.3.1 for details.
Variable height bed: Must meet fixed height criteria AND variable height necessary for ambulation/transfer.
Semi‑electric/Total electric bed: Semi‑electric: frequent position changes required, immediate changes needed, beneficiary can operate controls. Total electric: meets semi‑electric criteria and electric height needed for ambulation/ADLs.
Oversized bed: Meets standard equipment medical necessity; include height/weight/body measures and equipment dimensions/weight capacity on CMN/PA.
Pediatric specialty bed: Prescriber order; diagnosis supports special features; independent PT/OT evaluation or LON; environment suitability; caregiver capacity; explanation why regular bed inadequate.
Prior approval required.
DME medical necessity general
Top‑level DME medical necessity node: device coverage depends on meeting device‑specific criteria and documentation.
DME general medical necessity: Equipment is covered when beneficiary's diagnosis and condition make it medically necessary and documentation meets the specific criteria for that equipment type; prior approval is required as specified per equipment type.
See per‑equipment subsections for required documentation and prior approval instructions.
Medical necessity per equipment type
Illustrative device‑specific medical necessity examples (power wheelchair, complex rehab, power seating).
Standard Power Wheelchair Criteria: Significant MRADL impairment; inadequate response to cane/walker; insufficient upper extremity function for manual wheelchair; capability to operate power wheelchair safely; expected improvement in MRADLs; accessible environment; and face‑to‑face physician evaluation documented prior to order.
See Subsection 5.3.6 for full prior approval documentation list.
Complex Rehab Criteria: Requires specialized therapist evaluation and letter of medical necessity, need for special drive controls or seating features, and documentation of medical necessity for complex features in clinic evaluation.
Therapist must not have financial relationship with supplier.
Power Seating Systems Criteria: Tilt/recline needed for positioning, significant trunk/hip deformity or abnormal tone, inability to reposition independently, risk to skin integrity, cardiorespiratory/digestive benefit from tilt, >=6 hours/day wheelchair use, and no caregiver available to perform function.>=6 hours/day
Prior approval required.
Activity/Positioning and Power Seating Necessity
Activity/positioning and power seating medical necessity summarized.
Power seating summary: See Power Seating Systems criteria: tilt/recline indicated for positioning, trunk/hip deformity or abnormal tone, inability to reposition, risk to skin integrity, respiratory/digestive/cardiac benefit, >=6 hours/day wheelchair use, and no caregiver available.>=6 hours/day
Prior approval required.
Activity chair summary: Activity/Positioning Chairs covered when beneficiary meets any one functional/postural deficit (cannot sit in conventional seating, needs support for fine motor tasks, decreased trunk control, uses arms for balance, requires external support, lacks protective reactions, or needs upright position for feeding); PT/OT LON required for prior approval.
Therapist must be independent of supplier.
Gait trainer medical necessity
Gait trainer medical necessity aligns with coverage criteria in the Coverage section.
Gait trainer necessity: Moderate to maximal support for walking due to impaired balance or pelvic/trunk instability or GMFCS ≥3; beneficiary can initiate movement without caregiver assistance and movement is purposeful; PT/OT evaluation required and therapist must be independent of supplier.age 0-20 when specified
Prior approval for gait trainer with accessories.
AAC medical necessity
AAC medical necessity summarized with documentation requirements.
AAC necessity summary: Device medically necessary; dedicated to communication; used solely by beneficiary; long‑term severe communication impairment; prior approval for speech‑generating devices and extensive SLP evaluation and physician documentation required as specified.
Dedicated general‑purpose computing devices not modified for AAC are not covered.
Stander medical necessity
Stander medical necessity summarized for ages 0–20 with therapist documentation and least‑cost rationale.
Stander necessity summary: Requires moderate to maximal support for standing; cannot stand/ambulate due to long‑term condition; effective weight bearing cannot be achieved by other means; stander tried and used safely; environment accommodates stander; beneficiary motivated and caregiver able to follow program; PT/OT evaluation required and therapist must be independent of provider; documentation must show least expensive appropriate device and alternatives considered.age 0-20
Prior approval required.
Pediatric toileting equipment medical necessity
Pediatric toileting equipment device‑specific medical necessity summarized.
Toilet seat reducer: Beneficiary too small to sit safely on regular commode but can safely sit with reducer ring (age 0–20).age 0-20
Lo‑Back Toilet Support: Balance/trunk support needs, trunk weakness or tonal abnormalities, poor protective reactions, or inability to sit on regular toilet without caregiver assistance (age 0–20).age 0-20
Potty Trainer: Needed for out‑of‑bathroom training, stability deficits, or balance/coordination deficits (age 0–20); accessories require prior approval.age 0-20
Toileting System: Requires moderate to maximal support, significant balance/coordination deficits, poor head/trunk control, or will enable independence in toileting; therapist LON required and accessories require prior approval (age 0–20).age 0-20
Prior approval required.
rental/purchase mapping
Rental vs purchase mappingCapped rental items: anticipated need ≤ 6 months = rent; >6 months = may rent or purchase (documented). AAC devices and some other items have rental-before-purchase rules (rental fees may apply toward purchase).
Manual wheelchair rentalPrior approval for rental of a manual wheelchair is granted for a maximum of nine months.
AAC rental-to-purchaseAAC devices requiring PA generally require a one-month rental evaluation before Medicaid purchase; if rental unavailable, purchase PA may be granted with evidence of effective recent use.
Note
Oversized bed measurements
For oversized hospital beds include beneficiary height, weight, body measurements (appropriate position), equipment dimensions, and manufacturer's weight capacity on CMN/PA.
Documentation requiredProvider must submit physician/PA/NP order documenting bed/crib is most appropriate and supporting clinical documentation for prior approval of pediatric specialty beds.
electronics, upholstery replacement notes
Electronics replacement notesReplacement electronics for power wheelchairs require prior approval when the part cannot be repaired, warranty has expired, replacement extends wheelchair life, and cost is less than a new comparable wheelchair.
Upholstery replacementReplacement upholstery is covered when damaged or worn beyond repair; prior approval is not required for replacement upholstery.
Motor/gearbox replacementsMotor and gearbox replacements require prior approval and follow replacement electronics criteria (non-repairable, warranty expired, cost-effective vs new wheelchair).
power wheelchair components
Power wheelchair component replacement conditionsReplacement of power wheelchair components is covered when the part cannot be repaired, the warranty has expired, replacement significantly extends the life of the wheelchair, and the cost is less than a new comparable wheelchair.
No fixed intervalThere is no fixed replacement interval; decisions are based on repairability, warranty status, cost-effectiveness, and prior approval when required.
Prior approval required for many partsPrior approval is required for many electronics, motor and gearbox replacements; refer to fee schedule for items marked with an asterisk.
AAC devices lifetime expectancy and replacement windows
AAC lifetime expectancyLifetime expectancy for AAC devices is three years; repairs and replacement requests are governed by this expectancy.
Replacement sooner allowedAAC device may be modified or replaced sooner if beneficiary status changes, device is nonrepairable, warranty expired making repairs not cost-effective, manufacturer excludes repair from warranty, or device is damaged/stolen (with documentation).
Repair caps and cost limitsRepairs of AAC devices must not exceed $500 annually; total AAC device cost, accessories and repairs capped at $9,500 for a two-year period.
All DME — replacement as needed
All DME replacement ruleAll DME may be replaced as needed subject to lifetime expectancies and quantity limits listed in Attachment A Section C; early replacement requires explanation and documentation on CMN/PA.
Documentation for early replacementWhen requesting replacement before usual life expectancy, explain why replacement is needed on CMN/PA and submit supporting documentation (police/fire report, social worker letter, etc.) for loss or damage.
Service vs replacementReplacement is considered when repair is not cost-effective and item is out of warranty; refer to Subsection 5.8 and Attachment A for details.
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Reusable/removable characteristicDME can withstand repeated use and may be reusable or removable and is not typically useful without a disability or illness.
Refer to attachmentsRefer to Attachment A Section C for HCPCS codes, lifetime expectancies and quantity limitations tied to DME definitions.
Supplies definition
Supplies — consumable definitionSupplies are consumable or disposable items that cannot withstand repeated use by multiple individuals and are required to address an individual’s medical disability, illness, or injury.
Attachment rulesLimits, lifetimes and procedure codes for supplies are listed in Attachment A Section C; prior approval required for items not listed.
Replacement/repairReplacement of supplies follows durable medical equipment limitations and prior approval rules when applicable.
Durable Medical Equipment (ordering and medical necessity)
Ordering and medical necessity summaryDME must be ordered by a physician/PA/NP, be medically necessary to maintain or improve function, appropriate for noninstitutional use, with face-to-face encounter within 6 months and annual review; unlisted items require prior approval.
Categories and thresholdsCoverage categories (inexpensive/routine; capped rental; frequent servicing; related supplies; service/repair; individually priced) determine rental/purchase and prior approval rules.
Attachment A linkageRefer to Attachment A Section C for HCPCS codes, established lifetimes and quantity limits used in medical necessity and claims.
Pediatric Specialty Bed definition
Pediatric Specialty Bed definitionBeds such as SleepSafe, Courtney, Beds by George or Pedicraft with special safety features to prevent entrapment or falls for children with physical and cognitive disabilities who require an enclosed padded interior and quick access for medical attention.
Prior approval requirementPediatric cribs, pediatric hospital beds, safety enclosures and pediatric specialty beds require prior approval and clinical documentation.
Use-case examplesIntended for children who need head/foot adjustments not feasible in ordinary bed or who require special attachments not usable on ordinary beds.
MRADLs and significant impairment definition
MRADLs definitionMobility-related activities of daily living (MRADLs) are toileting, feeding, dressing, grooming, and bathing; 'significantly impairs' means prevents completion, delays completion, or places beneficiary at high risk of injury or morbidity.
Use in wheelchair criteriaSignificant impairment in MRADLs is a core criterion for manual and power wheelchair coverage decisions.
Assessment implicationsDocumentation must show how mobility limitation affects MRADLs to justify DME such as wheelchairs or mobility aids.
Pressure ulcer staging definitions
Pressure ulcer stagingStage I: non-blanchable erythema; Stage II: partial-thickness skin loss; Stage III: full-thickness skin loss to subcutaneous tissue; Stage IV: full-thickness with destruction to muscle/bone/supporting structures.
Relevance to support surfacesUlcer stage informs Group 1/2/3 support surface coverage and prior approval pathways.
Non-durable foam exclusionA foam overlay or mattress without a waterproof cover is not considered durable and is non-covered.
MRADLs componentsMRADLs: toileting, feeding, dressing, grooming, and bathing — used across policy to determine mobility-related needs.
Significance threshold'Significantly impaired' indicates inability to perform, excessive time, or high risk of injury when performing MRADLs.
ApplicationMRADL impairment is applied to determine coverage for mobility equipment, canes, walkers, and wheelchairs.
MRADLs duplicate definition
MRADLs restatementMobility-related activities of daily living (MRADLs) are toileting, feeding, dressing, grooming, and bathing; used consistently as coverage criterion.
Clinical useAssessments must document how mobility limitation impacts MRADLs for DME approvals.
Policy consistencyMRADL definition is referenced in multiple equipment sections (wheelchairs, canes, walkers, standers).
Gait trainer definition
Gait trainer definitionA wide-based frame with four casters that provides considerable postural support and may include positioners/stabilizers for beneficiaries with severe motor and balance dysfunction requiring moderate to maximal support.
Accessories and supportAdditional positioners or stabilizers can be added for extra support and control; therapist must document need for components.
Prior approval for accessoriesGait trainers with accessories require prior approval and PT/OT evaluation for beneficiaries age 0–20.
Gait trainer duplicate definition
Gait trainer (alternate wording)A wide-based frame with four casters providing significant postural support; positioners/stabilizers may be added for beneficiaries with severe motor and balance dysfunction.
Therapist evaluation requirementPT/OT evaluation must document need and therapist cannot be employed by equipment provider.
Age-based coverageMay be covered for beneficiaries aged 0–20 when criteria met.
Dedicated AAC device definition
Dedicated AAC deviceA device used only for communication purposes (not an unmodified laptop, desktop, or PDA) — must be dedicated to the beneficiary's communication needs.
Coverage documentationPrior approval requires physician report, itemized physician order, and qualified SLP evaluation documenting long-term severe communication impairment and device specifics.
Cost and lifespan limitsAAC devices have cost and repair caps ($9,500/2 years total cost; $500 repairs/year) and a three-year lifetime expectancy with allowed early replacement conditions.
Sit-to-stand stander definition
Sit-to-stand stander definitionEquipment that transitions a beneficiary who cannot stand independently from sitting to upright standing with support and the ability to stop at incremental points while bearing weight.
AccessoriesMay include accessories for support; standers and accessories require prior approval for beneficiaries age 0–20 with therapist evaluation.
Coverage criteriaCoverage requires PT/OT evaluation documenting need for moderate to maximal support and caregiver ability to carry out standing program.
Toilet Seat Reducer Ring definition
Toilet Seat Reducer RingA device that reduces the size of a commode opening and is medically necessary for beneficiaries age 0–20 who are too small to sit safely on a regular commode but can with the reducer ring.
Age restrictionCoverage limited to beneficiaries age 0 through 20 years.
No prior approval for basic unitSpecific accessories may require prior approval; check device section for accessory rules.
Lo-Back Toilet Support definition
Lo-Back Toilet Support definitionProvides posterior lower trunk support and reduced seat depth; medically necessary for beneficiaries age 0–20 with balance or trunk weakness, poor protective reactions, or inability to sit on regular toilet without assistance.
Age limitationCovered for beneficiaries age 0 through 20 years when criteria met.
Accessories and PAAccessories require prior approval and must be medically necessary to safely support toileting.
Potty Trainer definition
Potty Trainer definitionAdjustable seating device providing postural support and stability; medically necessary for beneficiaries age 0–20 when toileting outside a bathroom, unstable seating on commode, or deficits in balance/coordination/function.
Accessories require PAAll accessories require prior approval and must be medically necessary.
Therapist involvementPrior approval typically requires a therapist letter of medical necessity documenting least-expensive appropriate device and rationale.
Toileting System definition
Toileting System definitionA mounted or free‑standing system providing moderate to maximal support with interchangeable accessories — necessary when beneficiary cannot sit on a commode without full caregiver support or has significant balance/head/trunk control deficits.
Therapist documentationA letter of medical necessity from a PT/OT is required for prior approval and must document least-expensive appropriate device and alternatives considered.
Age limitation and PACovered for beneficiaries age 0–20 with prior approval and supporting documentation; accessories require PA.
This duplicate placeholder reiterates that Section 4.0 (When the Procedure, Product, or Service Is Not Covered) and Section 4.2 contain the policy's authoritative not‑covered criteria. Consult those sections and the device‑specific subsections when preparing documentation or prior approval submissions.
If a requested item appears to be excluded, consider whether an EPSDT exception (for beneficiaries under 21) or a formal prior approval with supporting medical evidence is appropriate.