CurrentKaiser PermanentePolicy N/A

Kaiser Foundation Health Plan of Washington Clinical Review Criteria for Durable Medical Equipment and Prosthetics

Defines medical necessity criteria, required documentation, exclusions, code guidance, and specific prosthetic/orthotic coverage requirements for Kaiser Foundation Health Plan of Washington members (Medicare and non-Medicare), including alignment with state law SHB 1669 effective 1/1/2026.

Policy Summary

PayerKaiser Permanente

PolicyKaiser Foundation Health Plan of Washington Clinical Review Criteria for Durable Medical Equipment and Prosthetics

Policy CodePolicy N/A

Change TypeMaterial updates (prosthetic coverage, exclusions, code lists)

Effective DateJan 1, 2026

Next Review Date

Key ActionInclude an order/prescription stating therapeutic purpose; clinical evaluation details of functional impairment related to ADLs; long‑term need when applicable; and documentation of trials of assistive devices that were inadequate or contraindicated.

POLICY UPDATE CHANGES

MPC approved criteria updates to align with WA state legislation SHB 1669 to include coverage (08/05/2025).

Effective January 1, 2026: Equipment and modifications/upgrades used primarily for leisure or recreational activities are excluded; prosthetic/adaptation coverage handled in separate prosthetic policies.

Added many specific codes to non-covered and applicable code lists across 2023-2025 (e.g., PureWick, Vitrectomy Chair added 02/04/2025 and 12/19/2024 updates).

Added PureWick Urinary Collection System to the DME non-covered list (05/31/2023).

MPC approved to include Light Therapy for Seasonal Affective Disorder to the DME policy (11/05/2024).

1Primary policy type

>=200

HCPCS/CPT codes listed (approx.)

2026-01-01SHB 1669 coverage effective date for renewals

3Replacement medical necessity reasons listed

Coverage Summary

This document defines clinical review criteria for Durable Medical Equipment (DME), prosthetics, and custom orthotic braces used to determine medical necessity and coverage for Kaiser Foundation Health Plan of Washington members (both Medicare and non‑Medicare). The criteria summarize needed documentation, exclusions, code guidance, and replacement rules to guide coverage determinations.

For Medicare members, applicable CMS guidance (NCDs, LCDs, and Local Coverage Articles) governs coverage where active Medicare guidance exists; in the absence of an active NCD/LCD/LCA, Kaiser uses these Clinical Review Criteria for DME determinations. For non‑Medicare members, the policy lists specific medical necessity criteria (e.g., documented functional impairment affecting ADLs, clinician prescription, published HCPCS code, and clinical rationale) that must all be met for DME to be considered medically necessary.

Per Washington state law SHB 1669 and related policy updates, for plans issued or renewed on or after 2026-01-01 the policy includes mandated coverage requirements for prostheses and custom orthotic braces (e.g., coverage for one or more prostheses per limb and custom orthotic braces per limb when medically necessary, inclusion of materials/components/related services, reasonable repair or replacement, and instruction to the enrollee).

Key facts

Primary policy typeDurable Medical Equipment (DME) and Prosthetics Clinical Review Criteria

Approx. HCPCS/CPT codes listed>=200

SHB 1669 effective date (plans issued/renewed)2026-01-01

Replacement reasons count3

StatusCURRENT

SubjectDurable Medical Equipment (DME) and Prosthetics Clinical Review Criteria

Medical Necessity and Exclusions

Coding

Non-covered / Personal Convenience Items (selected HCPCS/CPT/V-codes listed)mixedNot Covered

A4467	Belt, strap, sleeve, garment, or covering
A9270	Noncovered item or service
A9280	Alert or alarm device, not otherwise classified
L3000-L3090	Arch support
E0160	Sitz type bath or equipment, portable, used with or without commode
E0161	Sitz type bath or equipment, portable, used with or without commode with faucet attachment(s)
E0162	Sitz bath chair
E0235	Paraffin bath unit, portable
A4265	Paraffin, per pound
E0203	Telephone alert systems / therapeutic light box references

1–10 of 56

1/6

Codes Considered Medically Necessary when criteria met (selected)HCPCSCovered

E2601	General use wheelchair seat cushion, width less than 22 in, any depth
E2603	Skin protection wheelchair seat cushion, width less than 22 in, any depth
E2604	Skin protection wheelchair seat cushion, width 22 in or greater, any depth
E2605	Positioning wheelchair seat cushion, width less than 22 in, any depth
E2606	Positioning wheelchair seat cushion, width 22 in or greater, any depth
E2607	Skin protection and positioning wheelchair seat cushion, width less than 22 in, any depth
E2608	Skin protection and positioning wheelchair seat cushion, width 22 in or greater, any depth

Codes No Longer Reimbursed (no payment methodology by Medicare)HCPCSNot Covered

L2999	Lower extremity orthoses, not otherwise specified
L3999	Upper limb orthosis, not otherwise specified

Provider Actions & Authorization

Documentation Required

Required Documentation with DME Order

Include an order/prescription stating the therapeutic purpose of the DME and clinical evaluation details documenting the patient’s physical functional impairment related to completing ADLs. Document the patient's medical condition requiring long-term DME use when applicable (typically 6–12 months) and list what assistive devices were trialed and why they were inadequate, unsafe, or contraindicated.

Order/prescription stating therapeutic purpose
Clinical evaluation detailing physical functional impairment related to ADLs
Medical condition requiring long-term DME use (e.g., 6–12 months) when applicable
Documentation of trials of assistive devices (canes, walkers, manual wheelchairs) and reasons they were inadequate/unsafe/contraindicated

Prior Authorization

Background

Background: In 2012 Kaiser developed a reference list for DME/prosthetic equipment and devices to guide coverage when no specific medical policy exists; the Clinical Review Criteria were created to augment that reference list for determinations of coverage in the absence of other guidance.

For Medicare members the policy defers to applicable CMS documents (e.g., National Coverage Determination: Durable Medical Equipment Reference List (280.1) and relevant LCDs/Local Coverage Articles such as Oxygen and Oxygen Equipment L33797 and related policy articles); where active CMS NCDs/LCDs/LCAs exist, those govern. The SOURCE notes that in the absence of an active NCD, LCD, or other Medicare coverage guidance, Kaiser has chosen to use these Clinical Review Criteria for medical necessity determinations.

Role of these Clinical Review Criteria: When there is no active Medicare guidance or specific medical policy, these criteria provide the medical necessity framework for DME/prosthetic coverage decisions, specify items requiring clinical review (e.g., items billed with miscellaneous codes like ****99, K0108, L4205; items with no HCPCS code; new technology; devices not yet FDA approved), and document requirements for prosthetic/orthotic replacements and SHB 1669 compliance (definitions, coverage elements, and replacement thresholds such as repair cost > 60% of replacement cost and provider confirmation for replacements 3 years old).

Definitions

Medicare determinations

Revision History

08/05/2025policy_update

MPC approved criteria updates to align with WA state legislation SHB 1669 to include coverage for prosthetic limbs and custom orthotic braces (coverage requirements specified for plans issued/renewed on or after 01/01/2026).

01/01/2026effective_date

Effective January 1, 2026: Equipment and modifications/upgrades used primarily for leisure or recreational activities are excluded; prosthetic/adaptation coverage is addressed in separate prosthetic policies (per SHB 1669 and exclusions list).

05/31/2023policy_addition

Added PureWick Urinary Collection System to the DME non-covered list (position of non-coverage endorsed by MPC).

Policy Summary

PayerKaiser Permanente

PolicyKaiser Foundation Health Plan of Washington Clinical Review Criteria for Durable Medical Equipment and Prosthetics

Policy CodePolicy N/A

Change TypeMaterial updates (prosthetic coverage, exclusions, code lists)

Effective DateJan 1, 2026

Next Review Date

On This Page

Clinical Review Required for Specific Items

Submit items for Clinical Review when the request involves miscellaneous codes ****99, K0108, or L4205, when no HCPCS code exists for the item/service, when the item is new technology, when the item is not yet FDA approved or has received new FDA approval within the past 6 months, or when duplicate items of equipment are being requested.

Affected codes: ****99, K0108, L4205
Conditions requiring review: no HCPCS code; new technology; not yet FDA approved; new FDA approval within 6 months; duplicate items requested

Documentation Required

Prosthetic Replacement Confirmation

When requesting replacement of a prosthetic limb, custom orthotic brace, or a part thereof that is less than three years old, the prescribing health care provider may be asked to confirm the need for replacement.

Provider confirmation may be requested for replacements under 3 years

Billing Rule

Verify Authorization Requirements

Verify authorization requirements for specific DME items by using the Pre-authorization Code Check. For reimbursement and payment methodology clarification, refer to the Kaiser Permanente payment policy Durable Medical Equipment.

Use Pre-authorization Code Check to verify authorization requirements
See Kaiser Permanente payment policy Durable Medical Equipment for reimbursement clarification

11/05/2024policy_addition

MPC approved inclusion of Light Therapy for Seasonal Affective Disorder (SAD) to the DME policy (listed among non-covered/personal convenience items with therapeutic light box references).

2023-2025code_updates

Multiple code list updates and policy clarifications occurred across 2023–2025, including additions to non-covered and applicable code lists (examples: PureWick added 05/31/2023; applicable code updates 12/19/2024; Vitrectomy Chair added 02/04/2025).