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ModifiedIndiana Department of InsurancePolicy PROMOD00024

Durable and Home Medical Equipment and Supplies

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This policy governs coverage, documentation, authorization, billing, rental or purchase, repair, replacement, and use of durable medical equipment, home medical equipment, and medical supplies under Indiana Medicaid programs.

Policy Summary

PayerIndiana Department of Insurance

PolicyDurable and Home Medical Equipment and Supplies

Policy CodePolicy PROMOD00024

Change TypeModified — Version 7.0

Effective DateFebruary 1, 2026

Next Review DateN/A

Key ActionCheck the Professional or Outpatient Fee Schedule to determine whether a requested item requires prior authorization.

SourceLink

POLICY UPDATE CHANGES

Version 7.0 reorganized and edited policy text for clarity and updated the prior authorization requirements for medical equipment.

The revision added PathWays to the initial note and changed references from MCE to MCO.

The policy updated sections addressing manually priced DME, HME and medical supplies; capped rental items; repair and servicing; preferred diabetes supplies; contracted vendor and high-end incontinence products; parenteral and enteral nutrition pumps for home infusion; oximetry; and respiratory assist devices.

7.0Current policy version

8Updated subject areas

Prior authorizationUtilization management

DME, HME and suppliesService domains

30 daysSigned order submission deadline

Coverage Criteria

General DME/HME Requirements

Covered DME, HME, and medical supplies must satisfy applicable medical-necessity, ordering, documentation, prior-authorization, and billing requirements.

Prior authorization and medical necessity

The item is medically necessary for treatment of an illness or injury or to improve the member's functional level.
The item is adequate for the medical need; unnecessary convenience or luxury features are not authorized.
The anticipated period of need and item cost support the least-expensive rental or purchase option available to meet the member's needs.
The PA request includes the required written, signed prescription and, when applicable, a medical clearance form.

Policy Summary

PayerIndiana Department of Insurance

PolicyDurable and Home Medical Equipment and Supplies

Policy CodePolicy PROMOD00024

Change TypeModified — Version 7.0

Effective DateFebruary 1, 2026

Next Review DateN/A

Key ActionCheck the Professional or Outpatient Fee Schedule to determine whether a requested item requires prior authorization.

SourceLink

On This Page

Communication, Respiratory-Related and Diabetes Equipment

The following specialized equipment and supplies are covered only when the stated clinical, documentation, and authorization requirements are met.

Augmentative and alternative communication devices

The device or system compensates for congenital, acquired, or progressive loss or impairment of speech and is used for communication.
A medical doctor or doctor of osteopathy orders the device in writing and PA is approved.
Documentation shows sufficient mental and physical capability to benefit; inability to be effectively understood without the device; expected need for at least two years; and use to compensate for communication impairment.
The PA request includes medical-necessity documentation, a speech-language pathologist evaluation, identification of all suitable communication systems considering strengths, limitations, and environment, and a recommendation for the least-expensive device. Rental or purchase is based on the least-expensive option; lack of prior AAC use alone is not a denial reason.

AED and WCD replacement accessories

The member currently rents or owns the applicable AED or WCD.
A replacement battery is at least 11 months old or completely discharged.
Replacement electrodes have been used for at least 22 months or are proven broken or damaged beyond repair.
A replacement WCD garment is damaged or worn beyond repair and has been used at least five months.

Specialized car seats and car beds

PA is approved for HCPCS E1399 and one of the following is documented: significant limb spasticity, muscle flaccidity, or spinal deformity preventing safe use of a normal car seat; an independent OT or PT evaluation supporting the customized item; or a need to promote safe transfers not achievable otherwise.
Replacement is covered when the item no longer meets the member's growing needs or was involved in an accident and is unsafe. Customized-item billing and documentation rules apply.

Custom tracheostomy tubes

PA is approved for a manufacturer-substantially-customized tube to meet a specific medical need.
Clinical documentation supports medical appropriateness, and the prescriber explains why a standard or off-the-shelf tube cannot meet the need.
The item is billed with S8189 and the claim includes a cost invoice.

Additional diabetes testing supplies

Supply is limited to one month unless the manufacturer packages only larger quantities or Medicare allows a larger quantity.
A4253 is limited to four units, or 200 strips, per month; A4259 is limited to two units, or 200 lancets, per month. Additional units require PA.
PA for additional units includes a signed medical-necessity statement, a clear recommendation of additional units, and an HbA1c test within 90 days before the request.

Preferred diabetes supply products

Glucose meters, receivers, sensors, transmitters, and test strips on the Preferred Diabetes Supply List are prescribed or dispensed without PA when the product is preferred; nonpreferred products require PA based on medical necessity.
Claims include the complete vendor-specific NDC or UDI. Missing, invalid, mismatched, or improperly formatted identification causes denial. A nonpreferred product requires modifier U1, except Medicare crossover claims; a preferred product must not include U1.
Ancillary supplies such as syringes, pen needles, lancets, lancing devices, swabs, control solutions, and ketone strips are not subject to PDSL limitations.

Nutrition, Beds, Incontinence and Wound Therapy

Coverage requires medical necessity, applicable PA, and the documentation specified for the product and setting.

Food, nutritional supplements, and infant formula

No other means of nutrition is feasible or reasonable; routine or ordinary nutritional needs and nonnutritional use are not covered.
PA is required except for parenteral hyperalimentation and TPN. Determinations are case-by-case and convenience of the member or caregiver is not sufficient.
Items are billed on professional or outpatient claims, not pharmacy claims. Products furnished to LTC residents are included in the per diem, except eligible parenteral hyperalimentation and TPN.

Food thickener

A physician orders food thickener based on medical necessity and PA is approved.

Enteral nutrition

The supplier keeps the completed DME Information Form for Enteral and Parenteral Nutrition and physician-signed order in the medical record.
PA is required initially and after three, nine, and 18 months; after two years, further PA is case-by-case. If therapy is not medically required for two consecutive months, a new PA and renewal schedule are required.
Requests document special nutrients, caloric intake below 20 or above 35 calories/kg/day, and need for a pump. TPN with parenteral hyperalimentation does not require PA.

Enteral feeding cartridge

For B4105, PA is approved for up to three months when the member has cystic fibrosis with exocrine pancreatic insufficiency, failed standard pancreatic enzyme therapy demonstrated by failure to meet target weight gain for at least six weeks, and requires nightly continuous gastrostomy-tube feeding at least three times weekly to achieve caloric goals.
The request includes the DME information form and documentation supporting special nutrients and pump need; a professional claim includes MSRP or cost-invoice documentation.

High-frequency chest wall oscillation

PA includes a physician order, need for daily airway-clearance therapy, pulmonary testing within 90 days showing FEV1 at least 80% predicted, FVC at least 50% predicted, and a 25% one-year decrease in FEF 25-75, as applicable.
Documentation shows twice-daily chest physiotherapy or flutter devices failed, caregivers cannot provide effective therapy or the member is independent/away at school, continued hospitalization is a risk, and the member has no cardiac condition.
The generator requires a three-month rental before purchase; regular use, compliance, and tolerance must be documented. Replacement vest and hose are purchase-only.

Hospital and specialty beds

The bed is medically necessary in a noninstitutional setting, has a written physician order, and receives PA with a signed Medical Clearance Form, diagnosis, and medical-necessity documentation.
A hospital bed may be covered for medically ordered positioning not feasible with an ordinary bed, pain relief, head elevation above 30 degrees related to a qualifying condition after pillows or wedges fail, or traction requiring a hospital bed.
A variable-height bed additionally requires a need for height different from fixed height for transfers; a semi-electric bed additionally requires frequent or immediately needed position changes.

Enclosed or cubicle bed

All of the following are documented: qualifying diagnosis; daily seizures, uncontrolled movement, or self-injury; safety measures tried and failed; relevant injury, fracture, bleeding, aspiration, respiratory, or positioning history; signed physician order; and caregiver ability and willingness to clean and maintain the canopy.
The IHCP does not pay for laundering the mesh canopy.

Variable-height and semi-electric hospital beds

The member first meets the general hospital-bed criteria. Variable-height coverage requires transfer-related height need; semi-electric coverage requires frequent or immediate body-position changes.

High-end incontinence products

PA is approved for a high-end product based on medical necessity after applicable contracted-vendor products have been sampled and found unsuitable.
Documentation identifies the sampled products and reason for failure, such as leakage, skin breakdown, allergy, redness, irritation, or adhesive-related breakdown; it also documents actual monthly quantity and factors affecting change frequency.
Modifier U9 is included for designated high-end codes on FFS and managed-care DME claims, except crossover claims.

Negative pressure wound therapy

PA includes a physician order and reasonable, medically necessary use for a stage III or IV pressure ulcer, neuropathic ulcer, venous or arterial insufficiency ulcer, chronic mixed-etiology ulcer present at least 30 days, or traumatic or surgical wound.
Before NPWT, the record documents professional wound evaluation and measurements, moist dressings, debridement and infection treatment, adequate nutrition, and adequate perfusion.
For pressure ulcers, turning and positioning, an appropriate group 2 or 3 support surface for trunk/pelvis wounds, and moisture/incontinence management are addressed. Neuropathic ulcers require disease management and pressure reduction; venous ulcers require compression and encouragement of elevation and ambulation.

Bone Growth, Oxygen, Nutrition Pumps and Positive Airway Pressure

The following therapies require the specified clinical findings, certification, and continuation documentation.

Osteogenic bone-growth stimulators

Serial radiographs show cessation of fracture healing for at least three months, with at least two sets of multiple-view radiographs separated by at least 90 days.
Noninvasive electrical stimulation is limited to nonunion of long-bone fractures, congenital pseudoarthrosis, or specified high-risk spinal fusion. Noninvasive ultrasound additionally requires physician interpretation documenting no clinically significant healing; it is not used concurrently with another noninvasive stimulator.
Skull or vertebral nonunions, tumor-related nonunions, fresh fractures, and nonunion associated with osteomyelitis are not covered.

General home oxygen medical necessity

The treating provider documents severe lung disease or hypoxia-related symptoms expected to improve with oxygen, qualifying blood-gas or oximetry findings, consideration or failure of alternatives, and qualification under Group I, II, or III.
Transcutaneous oximetry may substitute for arterial or capillary blood gas when performed by a qualified provider other than the DME supplier, subject to the stated hospital exception.

Initial certification: Group I

Adults have PaO2 at or below 55 mm Hg or saturation at or below 88% at rest on room air; pediatric members have PaO2 at or below 60 mm Hg or saturation at or below 90%. Infants with BPD may qualify case-by-case with appropriate documentation.
Nocturnal-only coverage requires qualifying sleep findings with qualifying awake values or a significant sleep-related fall associated with hypoxemia symptoms. Exercise-only coverage requires qualifying exercise findings, nonqualifying resting values, and documented improvement with oxygen.

Initial certification: Group II

An adult has PaO2 56-59 mm Hg or saturation 89% or lower on room air plus dependent edema suggesting CHF, pulmonary hypertension/cor pulmonale, or hematocrit above 56%.
A pediatric member has a qualifying condition with severe or clinically significant chronic hypoxemia, including cystic fibrosis, BPD, qualifying sleep-disordered breathing, sickle-cell disease, pulmonary hypertension, or interstitial lung disease.

Initial certification: Group III

The member has PaO2 at least 60 mm Hg or saturation at least 90% on room air and documented episodes such as apnea, BPD, cerebral palsy, cyanotic congenital heart disease, severe asthma, intermittent cyanosis or dyspnea, airway obstruction, neuromuscular breathing impairment, recurrent epilepsy, intellectual disability with respiratory episodes, airway malacia, cluster headaches, pneumonia, COVID-19, or CHF.
Additional documentation states the type, frequency, and severity of episodes and recent ABG or oximetry results. PA may be for three, six, or 12 months.

Cluster headaches

The member has International Headache Society-diagnosed cluster headaches plus at least one ipsilateral autonomic finding or restlessness/agitation.
Initial approval is limited to three months. Renewal requires a current progress note describing frequency, duration, intensity, and positive response; renewal is denied if the pattern no longer qualifies. Only stationary gaseous oxygen E0424 and contents E0441 are covered.

Parenteral and enteral nutrition pumps

The record contains the completed DME Information Form for Enteral and Parenteral Nutrition and physician-signed order. The pump itself does not require PA, but enteral nutrition used with it does.

Myoelectric upper-limb prosthetics

For L8701 or L8702, the member is at least two years old, needs an upper-limb prosthesis, and has unilateral transhumeral or transradial deficiency.
The member can train, tolerate the prosthesis, operate it cognitively, has adequate proximal muscle signal, lacks contraindicating neuromuscular disease or environment, and has expert evaluation recommending it because a body-powered prosthesis is unusable or insufficient for ADLs.

CPAP coverage

The member has OSA with AHI or RDI at least 15, or AHI/RDI 5-14 plus qualifying sleepiness, cognition, mood, insomnia, hypertension, ischemic heart disease, or stroke history; alternatively, moderate/severe OSA exists where surgery is a likely alternative.
CPAP does not require PA, but the physician record retains the sleep-lab evaluation and polysomnography.

Restrictive thoracic disorders

For the first three months, BiPAP with or without backup may be covered when progressive neuromuscular disease or severe thoracic-cage abnormality is documented; PaCO2 is at least 45 mm Hg or sleep saturation is 88% or lower for at least five continuous minutes; progressive neuromuscular disease additionally may qualify with maximal inspiratory pressure below 60 cm H2O or FVC below 50%; and chronic pulmonary disease is not a significant contributor.

Severe COPD initial therapy

For the first three months, BiPAP without backup requires awake PaCO2 at least 52 mm Hg, sleep saturation at or below 88% for at least five continuous minutes while using oxygen at 2 LPM or usual FiO2, and OSA/CPAP considered and ruled out.

Severe COPD backup therapy

After at least 61 days of compliant therapy without backup, repeat testing shows PaCO2 remains at least 52 mm Hg and sleep saturation remains at or below 88% for at least five continuous minutes; the physician documents average use of four hours per 24 hours, lack of benefit, and medical necessity for backup. Approval starts a new three-month period.

Obstructive sleep apnea BiPAP

For the first three months, facility-based attended polysomnography establishes OSA and single-level CPAP has been tried and proven ineffective. Backup is not medically necessary when OSA is the primary diagnosis.

Hypoventilation syndrome BiPAP without backup

For the first three months, awake PaCO2 is at least 45 mm Hg, FEV1/FVC is at least 70%, FEV1 is at least 50% predicted, and sleep or immediately-awake PaCO2 worsens by at least 7 mm Hg or attended polysomnography shows saturation at or below 88% for at least five minutes without obstructive events.

Hypoventilation syndrome BiPAP with backup

For the first three months, a covered BiPAP without backup is being used, FEV1/FVC is at least 70%, FEV1 is at least 50% predicted, and PaCO2 worsens by at least 7 mm Hg or polysomnography on therapy shows saturation at or below 88% for at least five minutes without obstructive events.

Continued BiPAP coverage

A reevaluation occurs 61-90 days after initiation and documents symptom progress and device use. Continued coverage requires average use of at least four hours per 24 hours and benefit from therapy.
The treating physician signs and dates the compliance-and-benefit statement no sooner than day 61. Failure to meet compliance supports denial as not medically necessary.

Standers, Motorized Wheelchairs and Seating

Power mobility and seating systems require the applicable base criteria, medical clearance, and prior authorization.

General stander coverage

The stander is medically necessary in a noninstitutional setting and is a covered prone, supine, vertical, multipositional, or sit-to-stand model; mobile/dynamic standers are not covered, although the limited mobility option for a sit-to-stand stander may be covered for an appropriately capable member.
PA identifies brand, model, type, base price, attachments, and accessories and includes the signed standing-equipment clearance form, physician order, recent PT/OT evaluation, medical necessity, and physician-signed plan of care.
The plan includes measurable goals, expected standing time or potential for one hour daily, and expected benefits. Multipositional requests document complications such as postural drainage, suctioning, or postural hypotension; sit-to-stand requests document ability or near-term potential to rise and stand, with child decisions case-by-case.

Single-power-option groups 2 and 5

The member requires a drive interface other than a hand- or chin-operated standard proportional joystick, or meets criteria for a power tilt or recline system that is used on the wheelchair.

Single-power-option groups 3 and 4

The member has mobility limitation from a neurologic condition, myopathy, or congenital skeletal deformity, and requires a nonstandard drive interface or meets criteria for a power tilt or recline system used on the wheelchair.

Multiple-power-option groups 2 and 5

At least two of the following
- A ventilator is mounted to the wheelchair.
- A nonstandard drive-control interface is required.
- The member meets criteria for a power tilt or recline system used on the wheelchair.

Multiple-power-option groups 3 and 4

The member has mobility limitation from a neurologic condition, myopathy, or congenital skeletal deformity.
At least two of the following
- A ventilator is mounted to the wheelchair.
- A nonstandard drive-control interface is required.
- The member meets criteria for a power tilt or recline system used on the wheelchair.

No-power-option motorized wheelchairs

For groups 3 and 4, the member has mobility limitation from a neurologic condition, myopathy, or congenital skeletal deformity.

Power-operated vehicle coverage

The member cannot operate a manual wheelchair, has adequate trunk stability, can safely transfer, operate the tiller, maintain position, and safely use the POV, and does not require full power-wheelchair support.
CMS basic criteria, appropriate home access, weight limits, and significant improvement in MRADLs are documented. The POV is not needed only outside the home or for leisure/recreation; outdoor-oriented devices are denied.
The PA includes the completed motorized-wheelchair medical clearance form documenting inability to operate a manual wheelchair, safe operation and transfers, and trunk stability. Standard accessories are included in the initial rate.

Power tilt and/or recline seating system

The member qualifies for a power wheelchair that accommodates the system.
A qualified, licensed or certified rehabilitation professional evaluates the member and documents medical necessity in the home, work, school, or workshop; the evaluator has no financial relationship with the supplier.
One of the following additional needs
- The member cannot perform a functional weight shift and is at high risk for pressure ulcers.
- The member uses intermittent catheterization and cannot independently transfer from wheelchair to bed.
- The system is needed to manage increased tone or spasticity.

Covered equipment and supplies must be billed appropriately by an eligible provider, generally on the professional claim with the ordering provider's NPI. Code to the maximum level of specificity; miscellaneous codes are used only when no specific code applies, and require units and pricing documentation. Claims for consumable supplies use span dates matching the consumption period and are submitted after the span has ended; future service dates deny.

Medical supplies must serve a specific medical purpose and are covered only when medically necessary. Except for manufacturer packaging or qualifying Medicare exceptions, supplies may not exceed a one-month supply per calendar month. LTC facilities must include supplies and routine DME/HME in the per diem and may not bill them separately. Dialysis-related equipment and supplies are included in the renal dialysis composite rate.

Used DME is not reimbursed for purchase, except A4638 and A7046. Equipment initially placed as rental is new when later purchased; used rental equipment must be replaced with new equipment before FSSA purchase. Routine maintenance of functioning equipment, including testing, cleaning, regulating, and checking, is not covered. Repair is not paid when under warranty, caused by member misuse or abuse, or for rental equipment; rental providers are responsible. Repairs for LTC per-diem equipment are not separately reimbursable. Noncovered repair services include wheelchair or seating evaluations, patient education, measurement, and initial assembly.

LTC per-diem items include medical and nonmedical supplies, routine DME/HME, food and nutritional supplements, ordinary infant formula, standard wheelchairs, gloves, oxygen and oxygen-delivery supplies, and incontinence supplies. Separate reimbursement is limited to applicable customized, nonstandard, or medically necessary exceptions with PA. Nursing-facility and ICF/IID providers may not separately bill items included in the per diem.

Incontinence supplies are limited to members age three or older, $162.50 per month and $1,950 per rolling 12 months, supplied in 30-day increments. FFS incontinence, ostomy, and urological supplies must be obtained through the contracted vendor when applicable; claims from noncontracted vendors deny except qualifying Medicare or other-primary-insurer situations. High-end products require PA and modifier U9 as specified above.

Sterile and nonsterile gloves require a written physician order and documentation of treatment, dates, frequency, type, quantities, and proof of delivery when delivered or mailed. Gloves for paid caregivers, nonmedical use, dialysis, and LTC per-diem care are not separately covered. Nonsterile gloves are limited to 500 per month; sterile gloves are covered only when medically necessary and are not separately reimbursed in sterile kits.

AEDs and WCDs are capped-rental items, and the IHCP will not purchase both or rent both simultaneously for one member. Oxygen systems are rental-only and outside capped-rental rules; oxygen contents and accessories are included in the rental allowance, spare tanks and emergency inhalators are denied as precautionary, and oxygen codes use one unit per month. Oxygen for ordinary LTC care is in the per diem.

Wheelchairs, POVs, and motorized wheelchairs require PA and are generally limited to one per five years unless a significant documented change in medical need requires different equipment. Backup wheelchairs are denied. Standing wheelchairs are not covered. Standard motorized-wheelchair components and POV accessories are included in the base rate; upgrades and specified accessories require PA and medical necessity. Universal headrest plates are billed E1028, not E1399, and are covered only for documented fitting failure, changed condition, or justified replacement. Elevating leg rests require a qualifying knee-flexion limitation or cast/brace, significant edema, and a reclining back.

The IHCP does not separately reimburse outpatient orthotic or prosthetic devices when furnished on the same day as surgery; applicable devices may be separately reimbursed with revenue code 274 when rendered with treatment-room services. Prostheses are not covered for purely cosmetic purposes, although customizing features are exempt from PA after the basic prosthesis is approved.

For Hoosier Healthwise Package C, DME has a $2,000 annual or $5,000 lifetime benefit limit, excluding eyeglasses and medical supplies. For 590 Program members, billed amounts above $500 per procedure require PA. Items included in a facility per diem, renal dialysis composite rate, warranty, routine maintenance, or a noncovered product category must not be separately billed. Claims may deny or be subject to recoupment when orders are obtained after service, modified after service, lack required documentation, use an incorrect claim type, omit required NDC/UDI or modifiers, exceed quantity or rental limits, or fail PA requirements.

Medical Necessity Standards

Medical Necessity Criteria Summary

Medical necessity is determined case by case and requires the applicable general and equipment-specific criteria.

Medical necessity and adequacy: The equipment is medically necessary to treat illness or injury or improve functional level, is adequate for the medical need, and has no unnecessary convenience or luxury features.

Basic medical necessity: The item is medically necessary for an eligible member, ordered in writing by an appropriate IHCP-enrolled practitioner, and billed according to IHCP requirements.

Customized equipment: The item is uniquely constructed or substantially modified for the member, the physical condition requires customization, and construction costs, labor, materials, and pricing are documented.

Replacement equipment: The item is irreparably damaged or worn, the member's condition has significantly changed, or the item was lost through theft, fire, or natural disaster, and applicable documentation and PA requirements are satisfied.

AAC devices: The member can benefit cognitively and physically, cannot effectively communicate without the device, is expected to need it at least two years, and will use it to compensate for impaired communication.

AEDs and WCDs: The member would normally be a candidate for an implanted cardioverter defibrillator, implantation is contraindicated or the device must be removed, and nationally recognized guidelines support the requested AED or WCD.

Breast milk storage bags: Recent delivery, breast milk order or recommendation, adequate production potential, planned long-term pump use, pump-training capability, and separation or latch difficulty are documented.Maximum 200 per calendar month

High-frequency chest wall oscillation: Daily airway-clearance need, qualifying pulmonary-function findings, failed conventional therapy, inadequate caregiver therapy or independent living/school circumstance, hospitalization risk, and absence of cardiac disease are documented.

Hospital bed: Nonordinary positioning, pain-relief positioning, medically necessary head elevation, or traction requiring hospital-bed attachment is physician ordered.

Enclosed or cubicle bed: A qualifying diagnosis, daily seizures or uncontrolled movement or self-injury, failed safety measures, supporting history, signed physician order, and caregiver ability to maintain the canopy are documented.

NPWT: An eligible wound, reasonable and medically necessary therapy, physician order, completed wound-therapy measures, physician-signed clearance form, and ongoing wound-care progress are documented.Initial authorization 4 weeks; continuation requires updated PA documentation

Home oxygen: Severe lung disease or hypoxia-related symptoms are expected to improve with oxygen, qualifying blood-gas or oximetry evidence is present, alternatives were ineffective, and Group I, II, or III criteria are met.

Osteogenic stimulator: Qualifying fracture nonunion is established by serial radiographs and the requested device has a covered indication.At least 2 radiographic series >=90 days apart; healing ceased >=3 months

Myoelectric prosthetic components: The patient is at least 2 years old, needs an upper-extremity prosthesis, is a suitable candidate, has expert evaluation and recommendation, and cannot use a standard body-powered prosthesis adequately for activities of daily living.

CPAP: AHI/RDI is >=15 per hour; or AHI/RDI is 5–14 with a qualifying symptom or condition; or moderate/severe OSA has surgery as a likely alternative.AHI/RDI >=15, or 5–14 with qualifying symptom or condition

BiPAP devices: The member meets the pathway for restrictive thoracic disorder, severe COPD, OSA after ineffective CPAP, CSA after CPAP is ruled out with demonstrated improvement, or hypoventilation syndrome with the required blood-gas, spirometry, oximetry, and prior-device criteria.

Stander: The stander is medically necessary in a noninstitutional setting and the member can stand or has potential to stand one hour per day, with measurable goals and expected benefits documented.1 hour/day goal or potential

Power mobility: The member has significant MRADL limitations, cannot safely resolve them with a cane or walker, and cannot use a properly fitted nonmotorized wheelchair because of specified upper-body limitations; for a motorized wheelchair, long-term need and independent functional benefit are documented.

Power-operated vehicle: The member cannot operate a nonmotorized wheelchair, has adequate trunk stability, can transfer and operate the POV safely, has appropriate home access, meets weight limits, and will significantly improve independent MRADLs.

Universal headrest plate: Coverage is justified by failure of the initial headrest fitting, a changed condition involving a used wheelchair without a predrilled back, or a medically necessary replacement.

Rental, Purchase, and Capped Rental

Equipment or item	Classification	Key rule
DME and HME	Rental or purchase	Rental-versus-purchase rules apply; the policy contains separate sections for rental versus purchase and capped-rental items.
DME and HME	Rental	The PA contractor considers the anticipated period of need and item cost and selects the least expensive option that meets the member’s needs.
DME and other covered equipment for Hoosier Healthwise Package C	Rental or purchase	Members may rent or purchase equipment, depending on which option is more cost-efficient. The DME benefit limit is $2,000 per year or $5,000 per lifetime, excluding eyeglasses and medical supplies.
DME and HME	Rental or purchase	Select rental or purchase based on the least expensive option for the anticipated period of need; use the applicable Professional Fee Schedule modifier.
Standard rental equipment	Capped rental	Monthly rental payments continue until the rental price equals the purchase price; the equipment is then considered purchased and becomes FSSA property.
Items requiring frequent or substantial servicing	Rental only	Rental payments are allowed while the equipment remains medically necessary. Purchase claims are denied.
Capped-rental items	Capped rental	Rental is allowed only through the applicable six- or 10-month capped period. Afterward, the equipment is considered purchased and becomes FSSA property.
Augmentative and alternative communication device	Rental or purchase	The IHCP determines whether to rent or purchase the approved device based on the least expensive option that meets the member’s needs. An AAC device may not be denied solely because it is unavailable for rental.
AAC device trial	Trial rental	A rental trial may be authorized when the speech-language pathologist submits the trial duration, components, service-provider information, and member-specific success criteria.
Automatic external defibrillator and wearable cardioverter defibrillator	Capped rental	Both AEDs and WCDs are capped-rental items. The IHCP will not purchase both devices or rent both devices simultaneously for the same member.
Continuous passive motion device	Rental	Covered as a rental; bill one unit for each day of service with modifier RR.
High-frequency chest wall oscillation generator system	Capped rental	A three-month generator rental is required before purchase may be approved. Regular use, compliance, and tolerance must be documented at the end of the rental.
Replacement vest and hose	Purchase	Replacement vest and hose are purchase-only items and are not subject to the three-month generator rental requirement.
Noninvasive pulse oximeter	Rental or purchase	If more than eight CPT 94762 units are needed per month, provide the oximeter as a rental using E0445 RR. Purchase with E0445 NU is appropriate for expected long-term need when less costly than rental.
Liquid and gaseous oxygen systems	Rental only	Reimbursed as rental items only and not subject to capped-rental guidelines. One unit equals one month.
Parenteral and enteral nutrition pumps	Capped rental	Capped rental with no more than 10 monthly rental payments; at the end of the 10-month rental period, the pump becomes IHCP property.
Phototherapy bilirubin light	Rental	Bill E0202 with modifier RR; one unit equals one day. Coverage is limited to 15 units per member lifetime.
RAD accessories	Purchase or separate reimbursement	RAD accessories are reimbursed separately whether the RAD is owned or rented, subject to CMS guideline limitations.
BiPAP and CPAP humidifiers	Purchase only	Heated and nonheated humidifiers are single-patient-use, inexpensive items available for purchase only; no rental trial is required before purchase.
BiPAP and CPAP humidifiers for dually eligible members	Temporary rental exception	For members dually eligible for Medicare and Traditional Medicaid, the IHCP does not pay for purchase. Temporary rental is covered for Medicare and Medicare Advantage crossover claims only.
Tumor treatment fields device	Rental	The electric TTF device is billed with E0766 and modifier RR; replacement electrodes are billed separately under A4555.
Motorized wheelchairs	Rental	Basic-package exceptions must be submitted for prior authorization consideration when the wheelchair is rented.
Motorized wheelchairs	Purchase	Basic-package exceptions must be submitted for prior authorization consideration when the wheelchair is purchased.

Coding and Billing Reference

Operational Thresholds, Quantities and Billing Rules (inv-160–inv-236)

Prior authorization dollar thresholdAll services provided to 590 Program members with billed amounts greater than $500 per procedure require PA.

Medical necessity and cost standardThe item must be medically necessary, adequate for the medical need, and free of unnecessary convenience or luxury features. Rental versus purchase is determined by anticipated need and the least expensive option that meets the need.

Face-to-face timingFor specified home-health equipment and supplies, the face-to-face encounter must occur and be recorded no more than 6 months before the start of services.

Package C DME benefit limitMaximum $2,000 per year or $5,000 per lifetime; eyeglasses and medical supplies are excluded from the limit.

Professional claim requirementBill most DME, HME and medical supplies on CMS-1500, the IHCP professional portal or 837P, with limited pharmacy and outpatient-facility exceptions. Claims must include the ordering practitioner's NPI.

Miscellaneous-code billingUse an unlisted or miscellaneous code only when no more specific code matches. The PA request and claim must state units and include required pricing documentation.

Manual pricingReimbursement is 75% of MSRP, or 120% of cost invoice when no MSRP is available. MSRP or invoice documentation must be current and no more than 2 years old; altered or handwritten documentation may deny with EOB 6169.

LTC facility per diemMedical, nonmedical and routine DME/HME supplies, food supplements, nutritional supplements and most infant formulas included in the per diem are not separately reimbursable. Standard wheelchairs are included; only medically necessary customized wheelchairs may be separately covered.

Rent-to-purchase ruleMonthly rental continues until rental payments equal the purchase price, after which the equipment is considered purchased. Capped-rental equipment is considered purchased at the end of its 6- or 10-month capped period.

Capped-rental interruptionA break of 60 days or less does not interrupt the rental period. A break exceeding 60 days requires a new PA with documented justification; equipment replacement is generally limited to once every 5 years.

Used DME exceptionPurchase of used DME is not reimbursed except A4638 and A7046. Rental equipment later purchased for the member is treated as new; used rental equipment must be replaced with new equipment before purchase.

Repair billingUse K0739 for labor on repairs and nonroutine service of DME other than oxygen equipment. Attach itemized labor and materials invoices. Repairs under warranty, due to misuse or abuse, routine maintenance, rental-provider responsibility and LTC per diem items are not separately reimbursable.

Breast milk processing limitT2101 requires PA for up to 5,000 ounces and a written order plus qualifying infant and maternal medical criteria.

Breast milk storage bagsA4287 is limited to 200 bags per calendar month and requires documentation of medical necessity, planned breast-pump use and separation or latch-related difficulty; PA is not required.

AED and WCDE0617 and K0606 require PA. Both are capped-rental devices; the IHCP will not purchase both or rent both simultaneously for the same member.

AED/WCD accessory intervalsReplacement batteries generally require the device to be at least 11 months old or completely discharged; electrodes require 22 months of use or proof of irreparable damage; a WCD replacement garment requires at least 5 months of use and damage beyond repair.

CPM rentalE0935 and E0936 are billed with modifier RR; PA is not required and one unit equals one day.

Cranial remolding orthosisS1040 requires PA for members 4–24 months old with qualifying conditions and documentation of a failed minimum 2-month repositioning and stretching trial.

Custom tracheostomy tubeS8189 requires PA, clinical documentation explaining why a standard tube will not meet the member's needs, and a cost invoice.

Diabetes testing quantitiesA4253 is limited to 4 units (200 strips) per month and A4259 to 2 units (200 lancets) per month. Additional quantities require PA, medical-necessity documentation, a quantity recommendation and an HbA1c within 90 days.

Diabetes preferred productsNonpreferred glucose monitoring products require PA and modifier U1 on non-Medicare claims. Preferred products must not include U1; missing, invalid or mismatched NDC/UDI information denies. Medicare crossover claims follow the applicable Medicare modifier rules.

Enteral nutrition PA cycleEnteral nutrition requires PA initially and after 3, 9 and 18 months. After 2 years, renewal is case by case; two consecutive months without medical need restart the renewal schedule.

Enteral enzyme cartridgeB4105 requires PA and documentation of cystic fibrosis with EPI, failed standard enzyme therapy for at least 6 weeks, and qualifying nightly continuous tube feedings at least 3 times weekly.

Glove limitsA4927 is limited to 500 nonsterile gloves (5 units) per member per month and is for the patient, family or other unpaid caregiver. A4930 is covered when sterile gloves are medically necessary and not included in a sterile kit.

Chest-oscillation trialHigh-frequency chest wall oscillation requires PA and a 3-month rental trial before purchase. Purchase of replacement vest and hose is separate from the generator rental requirement.

Incontinence limitsMembers age 3 or older are limited to $162.50 per month and $1,950 per rolling 12 months, supplied in 30-day increments. High-end products require PA and modifier U9 except on qualifying crossover claims.

Crossover adjustment codesWhen primary insurance payment is zero for incontinence, ostomy or urological supplies, report ARC 1, ARC 2 or ARC 3 as applicable. Crossover claims are exempt from the 30-day, high-end PA and U9 requirements when the primary plan covered the product.

Home INR monitoringG0248 and G0249 are limited to Medicare or Medicare Advantage crossover claims. CPT 93792 and 93793 require PA; the member must have at least 3 months of anticoagulation, complete face-to-face training, document proper use and test no more than weekly.

NPWT supply limitsA6550 is limited to 15 wound-care sets per wound per month and A7000 to 10 canisters per wound per month unless increased quantities are medically documented and authorized.

Oximetry limitsCPT 94762 is limited to 8 units per month, with one unit equal to one day. For greater need, use E0445 with RR; E0445 requires PA for rental or purchase. Reimbursement for 94760–94762 includes interpretation and related equipment.

Cluster-headache oxygenApproval is initially limited to 3 months and requires current progress documentation for renewal. Only E0424 and E0441 are covered for this indication.

PhototherapyE0202 RR does not require PA; one unit equals one day and coverage is limited to 15 units per member lifetime.

Pneumogram94772 does not require PA. One pneumogram, regardless of channel count, equals one unit; use TC or 26 when billing only the technical or professional component.

Oxygen recertificationRecertification requires a new PA, Certificate of Medical Necessity and repeat ABG or oximetry. It occurs at 3 months in specified cases and annually for all members; annual testing must be within 6 months.

TTF deviceE0766 RR and A4555 require PA for qualifying newly diagnosed GBM. TTF must begin within 7 weeks of chemotherapy or radiotherapy, with KPS at least 70 and average use of 18 hours daily; A4555 requires MSRP or cost-invoice attachment.

Wheelchair replacement intervalReimbursement is limited to one manual wheelchair, power wheelchair or POV per 5 years unless a significant documented change in medical need warrants different equipment. Backup wheelchairs are not medically necessary.

Universal headrest plateUse E1028, not E1399. Coverage is limited to a failed initial headrest fitting, a medically necessary modification for a used wheelchair, or documented damage requiring replacement; the initial plate for a new wheelchair is not covered separately.

Power-assist deviceE0986 requires a qualifying manual wheelchair, relevant upper-extremity limitation, at least 1 year of self-propulsion and a specialty evaluation documenting need in the home.

BiPAP continuationAfter the initial 3 months, reevaluation must occur within 61–90 days. Continued coverage requires documented benefit and compliant use averaging at least 4 hours per 24-hour period, supported by a signed and dated treating-physician statement.

PEN pump rentalPEN pumps are capped rental items with no more than 10 monthly payments; the pump becomes IHCP property at the end of the rental period.

Prior Authorization and Provider Actions

Prior Authorization

Confirm PA and step-therapy requirements before dispensing

Check the Professional or Outpatient Fee Schedule before furnishing DME, HME, or supplies to determine whether prior authorization (PA) is required. Submit every PA request with a written, signed prescription; designated items may also require a medical clearance form, and customized or miscellaneous items require an itemized materials list.

The PA contractor selects rental or purchase based on anticipated period of need and cost, using the least expensive option that meets the member’s needs.
For 590 Program members, services with a billed amount greater than $500 per procedure require PA.
Customized items, replacement items subject to PA or quantity limits, AAC devices, AEDs/WCDs and accessories, specialized transportation equipment, cranial orthoses, custom tracheostomy tubes, high-end incontinence products, NPWT, bone-growth stimulators, oximeters, home oxygen, certain nutrition products, prosthetics, initial BiPAP and humidifiers, standers, TENS, TTF devices, wheelchairs, POVs, and applicable wheelchair options require the PA described in the applicable section.
A new PA request is required to begin a new capped-rental period after an interruption of more than 60 days when the break is justified and documented.
Follow required treatment sequences before requesting certain equipment: document failed repositioning and stretching before cranial orthosis, failed airway-clearance alternatives before chest-wall oscillation, failed pillows or wedges before qualifying hospital-bed head elevation, failed safety measures before an enclosed bed, failed standard enzyme therapy before enteral cartridges, and failed conventional wound therapy before NPWT.
For respiratory devices, follow the applicable sequence: COPD generally requires BiPAP without backup first; OSA requires an attended polysomnogram and a failed CPAP trial before BiPAP without backup; CSA requires CPAP to be ruled out when applicable; and hypoventilation with backup requires an already covered device without backup.

Documentation Required

Build and retain the required documentation record

Maintain a complete written order and supporting medical record for every DME, HME, or medical-supply service. PA submissions and claims must include the forms, clinical records, pricing support, and item-specific documentation required by the policy.

Include the patient’s name, order date, prescriber signature, body area when applicable, product type and size, quantity, frequency, anticipated duration, refill authorization, and number of refills; document long-term need in the medical record.
The ordering and supplying providers must retain the order and supporting documentation for seven years. If the order is incomplete, obtain written clarification from the prescriber before dispensing.
For specified home-health equipment and supplies, document a face-to-face encounter with a qualified treating practitioner no more than six months before the start of services.
Claims must identify the ordering practitioner’s NPI. PA requests require a written, signed prescription and, when applicable, a medical clearance form.
For manually priced items, attach current manufacturer MSRP support or an itemized cost invoice; the documentation must be no more than two years old. If no MSRP is available, include the notation: “MSRP is not available for the product billed.”
Customized items require an order explaining the physical condition requiring customization and itemized labor, materials, and pricing. Repair claims require itemized labor and materials invoices.
Maintain item-specific records, including AAC evaluations and trials, nutrition forms and signed orders, oxygen certificates and qualifying tests, NPWT wound measurements and progress, stander plans of care, respiratory sleep studies, prosthetic orders, and wheelchair or POV medical-clearance forms.
For incontinence supplies, maintain the diagnosis, current signed order, annual renewal, proof of delivery, and required nursing assessment; for wheelchairs and accessories, document the member’s condition, functional need, dimensions, and medical necessity.

Denial Risk

Avoid billing practices that trigger denial or recoupment

Claims may be denied or recouped when orders, codes, pricing documents, dates of service, claim channels, vendor rules, or medical-necessity records do not comply with the policy. Review the item and setting before billing and do not separately bill services or supplies included in a facility per diem or another bundled payment.

A PA request suspended for missing documentation is denied if the signed prescription is not submitted within 30 calendar days. Orders modified after service or obtained after service may result in recoupment.
Use the most specific available procedure code; do not use a miscellaneous code when a specific code exists. Miscellaneous-code claims and PA requests must identify units and include required pricing documentation.
Do not submit handwritten, modified, outdated, or otherwise unacceptable MSRP or cost-invoice documentation. Rental-only items must not be billed as purchases, capped-rental claims must not exceed the allowed continuous rental period, and used DME purchases are not reimbursed except A4638 and A7046.
Do not bill routine maintenance, warranty repairs, misuse or abuse repairs, rental-equipment repairs by a non-rental provider, or excluded evaluation, education, measurement, and initial-assembly tasks. Do not submit future-dated consumable-supply claims.
Bill Omnipod, Omnipod Dash, and V-Go disposable delivery devices through the pharmacy benefit, not on a professional claim. Use national codes instead of HCPCS S-codes for home infusion or enteral therapy when appropriate national codes are available.
Do not bill both an AED and WCD concurrently, and do not bill routine DME, supplies, gloves, nutrition products, incontinence supplies, or oxygen separately for LTC residents when included in the facility per diem.

Documentation Requirements

Documentation Required

Prepare item-specific prescriber and supplier records

Prescribers and suppliers must prepare, sign, retain, and submit documentation that establishes medical necessity and supports the specific item, quantity, setting, and period of need. Use the applicable medical-clearance forms and maintain records for postpayment review.

A written order is required for medical equipment and supplies and must contain the applicable patient, product, quantity, frequency, duration, refill, and prescriber information. Claims for DME and HME must include the ordering provider’s NPI.
For home-health equipment and supplies, document the qualifying face-to-face encounter no more than six months before services begin and address certification of medical necessity.
Retain the completed medical-clearance form and supporting clinical records for the applicable item: beds, TENS, NPWT, oxygen, standers, wheelchairs, motorized wheelchairs, and POVs.
For manual pricing, customized items, repairs, TTF electrodes, and custom tracheostomy tubes, attach the required MSRP, cost invoice, or itemized labor-and-materials documentation.
Document reason and supporting evidence for replacement, including significant medical change, irreparable wear, theft, fire, or natural disaster; submit a new PA when required.
For clinical equipment, retain the records that establish the applicable pathway: oxygen testing and certificate, bone-growth-stimulator radiographs, NPWT wound measurements and progress, INR education and testing plan, CPAP polysomnography, BiPAP symptoms and compliance, and cluster-headache response.
For standers, include the recent PT/OT evaluation, signed plan of care, measurable goals, expected standing time and benefits, and specialized-stander justification when applicable.
For wheelchair seating and accessories, document the member’s physical dimensions, medical need for programmable controls or options, headrest history, leg-rest criteria, qualified rehabilitation evaluation, and at least one year of manual self-propulsion for push-rim power assist.

Policy Definitions

Key Definitions

Durable medical equipment (DME)Equipment that withstands repeated use, is primarily and customarily used for a medical purpose, and generally is not useful to a member in the absence of illness or injury.

Home medical equipment (HME)Provider-prescribed equipment that sustains, restores, or supplants a vital bodily function and is technologically sophisticated, requiring individualized adjustment or regular maintenance.

Medical suppliesDisposable, nonreusable items that must be replaced frequently and are primarily and customarily used for a medical purpose.

Customized and custom-fitted itemsA customized item is uniquely constructed or substantially modified for an individual member and cannot be grouped with another item for pricing. A custom-fitted item is measured, assembled, fitted, or adapted to the member's body, disability, period of need, or intended use and does not meet the customized-item definition.

Continuous rental and manually priced itemsContinuous rental means rental without an interruption lasting more than 60 days; a provider change does not interrupt the period. A manually priced item is a procedure code without an established Medicare rate, reimbursed using acquisition-cost information submitted with the claim.

Communication, cardiac, respiratory, and nutrition equipmentAAC devices compensate for impaired speech communication; AEDs and WCDs are defibrillators for members who would otherwise be candidates for an implanted defibrillator when implantation is contraindicated or the device must be removed; RADs include CPAP, BiPAP with or without backup, and IPPB machines with built-in nebulization; PEN pumps are parenteral and enteral nutrition pumps used for home infusion.

Mobility terminologyMRADLs are mobility-related activities of daily living, including toileting, feeding, dressing, and bathing. PMDs include motorized wheelchairs and POVs. A POV is a scooter-like device for a member who cannot operate a nonmotorized wheelchair but has adequate trunk stability and does not require the full support of a power wheelchair. Standard drive control is a hand- or chin-operated proportional joystick; nonstandard controls include head control, sip-and-puff, and switch interfaces.

Not Covered Services and Items

The following items, services, or circumstances are generally not covered or not separately reimbursable under this policy: equipment that is not medically necessary, inadequate for the medical need, or includes unnecessary convenience or luxury features; rental-only equipment billed as a purchase; used DME purchases other than A4638 and A7046; routine maintenance; warranty, misuse, abuse, or improperly assigned rental-equipment repairs; and evaluation, education, measurement, or initial assembly billed as repair or servicing.

Items included in an LTC facility, nursing facility, ICF/IID, CRF/DD, or group-home per diem—including routine DME/HME, medical supplies, nonmedical supplies, applicable nutritional products, gloves, oxygen, and standard wheelchairs—may not be billed separately to the IHCP. Dialysis-related items are included in the renal dialysis composite rate. Incontinence, ostomy, and urological supplies furnished to residents of group homes, ICFs/IID, and nursing facilities are likewise included in the facility per diem. Separate inpatient attendant costs for pneumatic artificial voice systems or artificial larynges are not reimbursable when included in the hospital or facility per diem.

Routine or ordinary nutritional needs, nonnutritional or convenience-driven food requests, incidental or general-purpose supplies, supplies exceeding a one-month quantity without an exception, paid-caregiver gloves, non-treatment glove use, separately billed dialysis or ESRD gloves, and sterile gloves included in procedure kits are excluded. Designated FFS incontinence, ostomy, and urological supplies from noncontracted vendors are denied except under the primary-insurer exception. Appropriate national codes must be used for home infusion and enteral therapy when available; HCPCS S-codes are not reimbursed in that circumstance.

Additional product and clinical exclusions include concurrent AED and WCD purchase or rental, cranial remolding orthosis after age 24 months or with unmanaged hydrocephalus or craniosynostosis, excluded osteogenic-stimulator indications, spare oxygen tanks, emergency oxygen inhalators, noninvasive oximetry during a pneumogram, routine LTC oxygen, cosmetic prostheses, BiPAP with backup for primary OSA, and continued BiPAP use below the required average of 4 hours per 24-hour period. Phototherapy exceeding 15 units per member lifetime is not payable.

Mobile or dynamic standers, upgraded stander trays, standing wheelchairs, and backup wheelchairs are not covered. Standard wheelchairs remain within the LTC per diem unless the wheelchair is customized and medically necessary. Basic motorized-wheelchair components and standard programmable systems are included in the base package and are not separately billable. POVs used only outside the home, for leisure or recreation, or designed primarily for outdoor use are excluded. Initial universal headrest plates for a new wheelchair are not covered, and universal headrest plate billing under E1399 is denied; the required code is E1028.