CurrentCommunity Health Plan WashingtonPolicy MC.CP.MP.107

Durable Medical Equipment and Orthotics and Prosthetics Guidelines

Policy governing medical necessity, coverage criteria, and coding implications for durable medical equipment, orthotics, and prosthetics for members/enrollees of Centene-affiliated health plans (Community Health Plan Washington). It outlines general and equipment-specific criteria, exclusions, and documentation expectations.

Policy Summary

PayerCommunity Health Plan Washington

PolicyDurable Medical Equipment and Orthotics and Prosthetics Guidelines

Policy CodePolicy MC.CP.MP.107

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit prior authorization and supporting documentation demonstrating medical necessity, education/trial, and cost-effectiveness; spinal orthotics and certain prosthetics require mandatory secondary review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1policy identifier provided

multipleequipment-specific HCPCS groups listed

3general criteria groups

E0678–E0681example HCPCS codes

Medicaid/Medicare

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Coverage and Medical Necessity Criteria

Hip orthotics

ALL of the following

Ordered by an orthopedic surgeon
Must be documented in the medical record (order or operative note).
- ANY of the following
  - Total hip arthroplasty
  - Hip labral tear
Requests for hip orthotics for hip osteoarthritis in patients who are not surgical candidates will be reviewed on a case‑by‑case basis by a medical director and/or therapy advisor
Approval may require additional clinical documentation supporting medical necessity and lack of surgical candidacy.

HCPCS and Procedure Codes

Non-pneumatic compression devicesHCPCSNot Covered

E0678	HCPCS code for non-pneumatic compression device (listed as not medically necessary)
E0679	HCPCS code for non-pneumatic compression device (listed as not medically necessary)
E0680	HCPCS code for non-pneumatic compression device (listed as not medically necessary)
E0681	HCPCS code for non-pneumatic compression device (listed as not medically necessary)

No codes listed

Spinal orthotics (mandatory secondary review)HCPCSCovered

L0700	Spinal orthotic HCPCS code (requires mandatory secondary review)
L0710	Spinal orthotic HCPCS code (requires mandatory secondary review)
L0720	Spinal orthotic HCPCS code (requires mandatory secondary review)
L0999	Spinal orthotic HCPCS code (requires mandatory secondary review)
L1000	Spinal orthotic HCPCS code (requires mandatory secondary review)
L1001	Spinal orthotic HCPCS code (requires mandatory secondary review)
L1005	Spinal orthotic HCPCS code (requires mandatory secondary review)
L1006	Spinal orthotic HCPCS code (requires mandatory secondary review)

No codes listed

Hip orthoticsHCPCSCovered

L1640	Hip orthotics HCPCS codes
L1680	Hip orthotics HCPCS codes
L1685	Hip orthotics HCPCS codes
L1686	Hip orthotics HCPCS codes
L1690	Hip orthotics HCPCS codes

No codes listed

Breast prosthetics (medically necessary post-mastectomy or for gender dysphoria)HCPCSCovered

L8030	Breast prosthetics HCPCS code
L8035	Breast prosthetics HCPCS code

No codes listed

Myoelectric rehabilitation systemsHCPCSNot Covered

E0738	Myoelectric Rehabilitation Systems (listed as not medically necessary)
E0739	Myoelectric Rehabilitation Systems (listed as not medically necessary)

No codes listed

Robotic arm (JACO)HCPCSNot Covered

E1399

Miscellaneous DME (used here for Robotic Arm, wheelchair-mounted (JACO), listed as not medically necessary)

No codes listed

Provider Responsibilities and Prior Authorization

Prior Authorization

Mandatory Secondary Review

Requests for spinal orthotics and certain prosthetics require mandatory secondary review by a medical director and/or therapy advisor. Submit clinical justification and any prior evaluation notes to support the request.

Affected HCPCS examples: L0700, L0710, L0720, L0999, L1000, L1001, L1005, L1006 (spinal orthotics)
Affected HCPCS examples: L6000–L6388 series (upper extremity and myoelectric prosthetics)

Documentation Required

New Equipment Supporting Documentation

For new or novel equipment, include supporting documentation from the supplier or manufacturer describing the device design, intended purpose, method of use, and any available clinical test results or studies. When applicable, provide documentation or consultation notes from specialists in physical medicine and rehabilitation to establish the item meets the definition of medical equipment and is appropriate for the member.

General DME Medical Necessity Requirements

General DME criteria

General DME medical necessity requirements:

General DME necessity: Equipment is necessary and reasonable for treatment of an illness or injury or to improve function; education and/or a trial with demonstrated safe and effective use must be provided.

Reasonableness includes consideration of cost relative to benefit and availability of less costly appropriate alternatives; see policy for detailed factors.

General DME rental & purchase rules

General DME rental & purchase rules and related considerations:

Durability and place of service: An item is considered durable if it can withstand repeated use (i.e., the type of item that could normally be rented). For rental/purchase determinations, the member/enrollee's home is defined per policy; institutional settings that meet hospital or skilled nursing facility definitions may not be considered the member's home.

Durability guidance and home/place‑of‑service rules inform rental vs purchase decisions.

Documentation and Supporting Evidence

Documentation Required

Medical necessity, trial, education, and supplier/specialist support for novel/custom devices

Documentation for novel or custom devices must show medical necessity, include demonstration or trial with evidence of safe and effective use, and document education; supplier/manufacturer or specialist documentation may be required to support the device's medical purpose and design.

Explain why prefabricated options are insufficient when requesting custom prosthetics.

Prior Authorization

Follow plan-specific documentation and prior authorization processes

Follow the member's coverage documents and applicable Health Plan administrative policies for specific documentation and prior authorization requirements; this policy is a guide and does not replace plan-level procedures.

Confirm plan-specific prior authorization processes and required submission materials before requesting authorization.

Background

Durable medical equipment (DME) refers to reusable items primarily used for medical purposes in the home that can withstand repeated use. Orthotics are devices that support or restrict motion of a body part, while prosthetics replace a missing body part or function. This policy uses these definitions to guide coverage decisions and to outline medical necessity, documentation, and review requirements for DME, orthotics, and prosthetics.

Definitions

Durable medical equipment (DME) definition

DefinitionDurable medical equipment (DME) — equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, is appropriate for use in the home, and is generally not useful in the absence of an illness or injury.

Durability criterionCan withstand repeated use (characteristic that typically makes an item rentable).

Place of useAppropriate for use in the member/enrollee's home (not generally intended for institutional settings).

Orthotics and prosthetics — definitions

Orthotic deviceRigid or semi-rigid device used to support a weak or deformed body part or to restrict or eliminate motion in a diseased or injured body part.

Prosthetic device

Not Covered Items

NOT COVERED (summary): The policy identifies the following as not medically necessary based on insufficient evidence—non‑pneumatic compression devices (HCPCS E0678–E0681), myoelectric rehabilitation systems (HCPCS E0738–E0739), and the JACO wheelchair‑mounted robotic arm (HCPCS E1399). Claims for these items are subject to denial under the plan unless specific coverage rules state otherwise.