Durable Medical Equipment Clinical Coverage Criteria
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Defines Fallon Community Health Plan's medical necessity, prior authorization, rental/purchase, and exclusion rules for durable medical equipment for plan members, and describes hierarchy of guidance applied by product (Medicare, MassHealth, Dual, Community Care, PACE).
Effective July 1, 2025, prior authorization requests for DME for all plan members should be submitted to Integrated Home Care Services (except PACE members).
Clarified hierarchy of criteria used to determine medical necessity across product lines (Medicare NCD/LCD, MassHealth Guidelines, Fallon Health policies, then MCG Care Guidelines).
Coverage Criteria for Durable Medical Equipment
General coverage
DME is covered when ALL of the following are met:
These are required for coverage
Ordering and prior authorization
Coverage requires ALL of the following provisions:
Someone other than the treating physician may prepare the order details, but the treating physician must personally sign and date the order
Rental and purchase
Rental/purchase coverage rules:
MassHealth ACO capped rental months require modifiers KH, KI, KJ as specified in the policy
Supplier is responsible for repair/maintenance during capped rental period
Continuous monthly rental
Continuous monthly rental items are covered when:
Coverage continues while medically necessary
Useful lifetime and replacement
Computation of useful lifetime based on delivery date to plan member
The following items are generally not covered under Fallon Community Health Plan’s DME policy unless a specific product benefit or regulation provides coverage: custom DME (items uniquely constructed or substantially modified for an individual), convenience items, backup equipment (except a manual wheelchair used as a backup to a power mobility system for MassHealth members who meet 130 CMR 409.413(D)), disposable equipment, and personal comfort items. These exclusions apply unless otherwise stated in the member’s Evidence of Coverage or required by regulation.
Items that are not primarily medical in nature or that serve convenience, personal comfort, or general adaptive purposes are considered not covered unless a regulation or a specific plan benefit explicitly provides coverage. Examples include environmental or non-medical devices such as air conditioners and dehumidifiers, general exercise equipment, and many adaptive aids (see exclusions list) — coverage requires that equipment be primarily used for a medical purpose and meet the policy’s DME definition.
Medical Necessity Criteria
DME medical necessity
DME is medically necessary when all general coverage criteria are met and documented:
Hierarchy of external guidance (Medicare NCD/LCD, MassHealth guidelines, Fallon policies, MCG) applies depending on product
Rental and Purchase Rules
| Rule | Details |
|---|---|
| Standard capped rental period | |
| For all products except MassHealth ACO, Fallon Health pays 10 monthly rental payments (equal to the allowed purchase amount) while equipment is in continuous use; interruptions >60 consecutive days plus remaining days in the rental month start a new capped rental period. End of capped rental period = item considered purchased and title transfers to plan member. | |
| MassHealth ACO capped rental period | |
| Effective December 1, 2020, for MassHealth ACO plan members Fallon will pay 13 monthly payments equal to the allowed purchase amount when the item is in continuous use; suppliers must use capped rental modifiers KH (1st month), KI (2nd–3rd months), and KJ (4th–13th months) unless contract specifies otherwise. | |
| What's included in capped rental payment | |
| Capped rental payment is inclusive of maintenance, service, repairs/replacement, and supplies and accessories needed for effective use; supplier retains title during rental and must transfer title at the end of the capped rental period. |
| Item class | Rental rule |
|---|---|
| Continuous-service equipment | |
| Items requiring frequent and substantial servicing are covered on a continuous monthly rental basis until medical necessity ends. Monthly rental is inclusive of all costs necessary for effective use, including supplies and accessories. No coverage is provided for purchase of these items or separate reimbursement for maintenance, servicing, repair, or replacement. |
| Topic | Fallon Health approach |
|---|---|
| Useful lifetime / replacement interval | |
| Reasonable useful lifetime for DME is 5 years from delivery; replacement before 5 years allowed if irreparably damaged, lost/stolen, or due to change in patient condition with required proof; misuse or wrongful disposition is not covered. | |
| Supplier title and determination of rent vs purchase | |
| Fallon Health will determine whether an item is purchased or rented. When rented (including capped rental), the supplier retains title during the rental period and must transfer title to the plan member at the end of a capped rental period. |
Billing, Repair, and Exclusion Codes
| K0739 | Repair or non-routine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes |
| E1399 | Durable medical equipment, miscellaneous |
| K0108 | Miscellaneous wheelchair part |
| K0462 | Temporary replacement for patient-owned equipment being repaired, any type |
| E0172 | Toilet seat lift mechanism |
| E0240 | Bath/shower chair |
| E0241 | Bathtub/toilet rail |
| E0242 | Bathtub/toilet rail |
| E0243 | Bathtub/toilet rail |
| E0244 | Raised toilet seat |
| E0274 | Over-bed table |
| E0621 | Patient lift |
| E0622 | Patient lift |
| E0623 | Patient lift |
Provider Actions & Prior Authorization
Submit prior authorization to Integrated Home Care Services
Effective July 1, 2025, prior authorization requests for durable medical equipment for all plan members (except PACE members) must be submitted to Integrated Home Care Services by fax to 844-215-4265. PACE member prior authorizations continue to be submitted to the PACE interdisciplinary care team.
Cost-comparison authorization rule
Integrated Home Care Services will authorize DME only when the requested equipment is not more costly than an alternative service, sequence of services, device, or equipment that is at least as likely to produce equivalent therapeutic or diagnostic results.
Required written order contents
A written order signed and dated by the treating physician is required and must include the start date, duration of need, a sufficiently detailed description of the item (brand, model, accessories/options), HCPCS code(s), and documentation of medical necessity (patient condition, abilities, limitations). The supplier must have the treating physician's written order before dispensing DME.
Replacement documentation required for early replacement
Proof of loss or irreparable damage is required to cover replacement of DME before the 5‑year useful lifetime; acceptable documentation includes a police report, photograph, or corroborating statement.
Prior authorization required (not a guarantee of payment)
Prior authorization is required for DME and must be obtained from Integrated Home Care Services when required; prior authorization does not guarantee payment and coverage remains subject to eligibility at the time of service.
Documentation Requirements
Treating physician must sign and date the order; supplier must have order before dispensing
The treating physician (or delegated NP/PA) must personally sign and date the written order; suppliers must have that written order from the treating physician before dispensing any DME to a plan member.
Supplier must provide corroborating documentation for replacement requests
For replacement requests when an item is lost, stolen, or irreparably damaged, the supplier or provider must supply corroborating documentation such as a police report, picture, or corroborating statement to support coverage.
Definitions
Replacement and Useful Lifetime
Items Not Covered
Not covered under this DME policy (unless a regulation or specific plan benefit applies): custom DME; convenience items; backup equipment (general exclusion, with the limited MassHealth manual wheelchair exception noted above); disposable equipment; and personal comfort items. The policy further excludes equipment that is not primarily medical (e.g., air conditioners, dehumidifiers), safety equipment (harnesses, restraints, protective helmets, car seats, etc.), many adaptive aids (toilet seat lifts HCPCS E0172, bath/shower chairs E0240, bathtub/toilet rails E0241–E0243, raised toilet seats E0244, over‑bed tables E0274, patient lifts E0621–E0642, standing frames E0637–E0642, stair lifts), wheelchair ramps, and home modifications unless covered by regulation or specific benefits.
Background
Durable Medical Equipment (DME) are items that can withstand repeated use and are primarily and customarily used for medical purposes in the home. To qualify for coverage the equipment must meet the DME definition, be medically necessary to treat the plan member’s illness or injury or to improve function of a malformed body part, and be used primarily in the member’s home. The policy excludes items that do not meet these characteristics or that are intended principally for convenience, comfort, or non‑medical use.
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