Kaiser Permanente DME Coverage Update

Coverage Criteria

General DME medical necessity

Covered when ALL of the following are met

DME medical necessity general criteria: 1) Documented physical functional impairment or disability due to disease, trauma, congenital anomaly, or prior therapeutic intervention requiring accommodation for basic activities of daily living (ADLs) that can be met by the requested DME item; 2) Documentation in the medical record contains a clinical assessment and rationale for the requested DME item; 3) The DME is prescribed by a health care practitioner; 4) The item has a published HCPCS code; 5) The equipment meets the definition of DME; 6) The requested DME item is not considered not medically necessary, investigational, or unsafe by a regulatory agency and is not excluded by plan benefits or contract exclusion; 7) When specific criteria exist for the item, the patient has also met those criteria.

Prosthetics

Prosthetics coverage

Prosthetics criteria: 1) The device replaces all or part of an internal body organ OR replaces all or part of the function of a permanently inoperative or malfunctioning internal body organ; AND 2) When specific medical criteria exist for the prosthetic, the patient has also met those criteria.

Items with no HCPCS code, miscellaneous coding (****99, K0108, L4205), new technology, duplicate items, and other items listed require clinical review as noted in the policy.

Replacements

Replacement criteria for prosthetics/custom orthotic braces

Replacement considered medically necessary if: Change in the physiological condition of the patient; irreparable change in the condition of the device or a part of the device; the device or part requires repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device or part; confirmation from the prescribing provider may be required if the prosthetic limb or custom orthotic brace or part being replaced is less than three years old.60% repair cost threshold

Confirmation may be requested when prior device is <3 years old.

Medically Necessary — general statement

Considered medically necessary when ALL of the following are met:

General: Items listed are considered medically necessary when the criteria in the applicable policy statements referenced above are met.

Reference the specific policy statements for item-specific clinical criteria and applicable HCPCS codes.

Accessory add-ons and upgrades are considered not medically necessary when a basic DME item adequately meets the member’s functional needs. Examples include comfort or convenience additions to standard equipment, deluxe upgrades when a basic device is sufficient, duplicate or backup items that are not the primary device, and equipment or modifications intended primarily for leisure or recreational activities. Also excluded are athletic/exercise/physical fitness equipment and devices used for environmental control or to enhance surroundings (for example, air conditioners, air filters, humidifiers, and related furniture).

Certain specific items and HCPCS codes are explicitly listed as not covered. Notably, A7001 (canister, non-disposable, used with suction pump) and A7002 (tubing, used with suction pump) are not covered when used with a disposable external urine management system. The policy also identifies other individually listed non-covered devices added over time (for example, the Relief Band device and the PureWick urinary collection system) and administrative listings of codes without Medicare payment methodology (e.g., L2999, L3999).

The policy lists an extensive set of items considered not medically necessary, including many comfort, convenience, and recreational devices (e.g., therapeutic lightboxes, whirlpools, treadmills, exercise equipment), household or environmental items (e.g., bath chairs, tub stools, air cleaners, dehumidifiers), first-aid or precautionary items, home modifications and institutional-only equipment, and various personal convenience items (e.g., wigs, topical hyperbaric oxygen chambers). The Applicable Codes sections enumerate numerous HCPCS codes that correspond to these non-covered items for billing and prior authorization reference.

Devices that are not primarily intended for medical purposes (for example, desktop or laptop computers, smartphones, tablets, internet or phone services, and non‑medical residential modifications) are included in the policy’s not medically necessary exclusions and are not reimbursable as DME.

Coding and HCPCS

Considered non-covered / listed codes (excerpt)HCPCSNot Covered

A4467	Belt, strap, sleeve, garment, or covering, any time
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	Therapeutic lightbox, minimum 10,000 lux, table top model

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Applicable HCPCS/Codes (partial list)HCPCS

E0246	Tub rail attachment for transfer.
E0247	Transfer bench for tub or toilet with or without commode opening.
E1050	Combination wheeled walker with seat and transport chair, folding, adjustable or fixed height.
E0248	Transfer bench, heavy-duty, for tub or toilet with or without commode opening.
A4575	Topical hyperbaric oxygen chamber, disposable.
E0446	Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories.
L8510	Voice amplifier.
E0249	Pad for water circulating heat unit, for replacement only.
E0950	Wheelchair tray.
E1301	Whirlpool tub, walk-in, portable.

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Applicable HCPCS/Codes (continued)HCPCS

V5283	Assistive listening device, personal FM/DM neck, loop induction receiver.
V5284	Assistive listening device, personal FM/DM, ear level receiver.
V5285	Assistive listening device, personal FM/DM, direct audio input receiver.
V5286	Assistive listening device, personal blue tooth FM/DM receiver.
V5287	Assistive listening device, personal FM/DM receiver, not otherwise specified.
V5288	Assistive listening device, personal FM/DM transmitter assistive listening device.
V5289	Assistive listening device, personal FM/DM adapter/boot coupling device for receiver, any type.
V5290	Assistive listening device, transmitter microphone, any type.
A7001	Canister, non-disposable, used with suction pump, each
A7002	Tubing, used with suction pump, each

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Codes without Medicare payment methodology (no longer reimbursed)HCPCSNot Covered

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

Wheelchair seat cushion HCPCS codes (medically necessary when criteria met)HCPCSCovered

E2601	General use wheelchair seat cushion, width less than 22 in, any depth.
E2602	General use wheelchair seat cushion, width 22 in or greater, 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 dept.
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.

Replacement review age threshold — less than three years (confirmation may be required)

Replacement review age thresholdConfirmation from prescribing provider may be required if the prosthetic limb or custom orthotic brace (or part) being replaced is less than three years old.

Replacement clinical reasonsReplacement may be medically necessary for change in patient physiological condition or irreparable change in device/part.

Repair-cost thresholdReplacement considered if repair cost would be more than 60% of replacement cost for the device or part.

Wheelchair cushion width threshold — 22 in

Wheelchair cushion width threshold22 in (cushions with width 22 in or greater are distinguished in HCPCS codes E2602, E2604, E2606, E2608).

Provider Actions & Prior Authorization

Note

Items considered medically necessary

Durable medical equipment (DME) items are considered medically necessary when ALL applicable criteria in the policy are met, including documented functional impairment related to activities of daily living (ADLs), a clinical rationale tying the DME to the patient’s functional needs, and a valid prescription from a licensed provider. Items must have a published HCPCS code, meet the definition of DME, not be excluded by plan benefits or regulatory action, and satisfy any device‑specific criteria described elsewhere in the policy.

Provider action: Items are considered medically necessary when criteria in the applicable policy statements listed above are met.

Documentation Required

Trial of simpler devices

Documentation should indicate which simpler or less‑intensive assistive devices were trialed and why they were inadequate, unsafe, or contraindicated prior to requesting more complex DME. Examples of devices to document trial/use of include canes, walkers, manual wheelchairs, and other non-powered aids. The clinical record should clearly state duration and results of trials and rationale for escalation to the requested equipment.

Background

Durable medical equipment is intended to accommodate basic activities of daily living (ADLs) for members with functional impairment due to disease, trauma, congenital anomaly, or prior therapeutic intervention. DME supports self-care activities in the member’s residence—such as dressing, bathing, eating, ambulating, toileting, transferring, and hygiene—and must be prescribed and justified by clinical documentation demonstrating that the equipment addresses the member’s functional needs.

Definitions

ADLs — Activities of daily living

DefinitionActivities of daily living (ADLs) are self-care activities done daily within a member's place of residence.

ExamplesIncludes dressing/bathing, eating, ambulating (walking), toileting, transferring, and hygiene/grooming.

Context of useADL impairment is a required element of documented functional need when requesting DME for home use.

Durable Medical Equipment (DME)

DefinitionDurable Medical Equipment (DME) is equipment primarily and customarily used to serve a medical purpose and not useful in the absence of illness or injury.

Key characteristicsOrdered or prescribed by a physician or qualified provider; reusable (non-disposable); designed to withstand repeated use (durable); not solely for convenience of patient or caregiver.

Medical Necessity — Equipment-Specific

Equipment-specific necessity

Equipment-specific necessity: Device must replace or restore function or organ as defined for prosthetics, or otherwise meet the General DME medical necessity criteria and any applicable item-specific criteria described in the relevant policy statements.

Clinical review may be required for items without HCPCS codes, miscellaneous coding, new technology, and items specifically listed for review.

Wheelchair cushion criteria reference

Wheelchair cushions: HCPCS codes E2601–E2608 (general use, skin protection, positioning, and combined cushions) are considered medically necessary when the criteria in the applicable policy statements listed above are met.

See associated policy statements for the specific clinical criteria; width threshold referenced in coding is 22 in for classification purposes.

Rental & Purchase Rules

Equipment	Rental/Purchase Rule	Notes
Oxygen equipment	Bundled rental	Oxygen reimbursement is a bundled payment; all options, supplies, and accessories are considered included in the monthly rental payment for oxygen equipment.

HCPCS code	Description	Coverage status	Notes / Rationale
L2999	Lower extremity orthoses, not otherwise specified	Not Covered	Codes without payment methodology by Medicare; more specific codes should be used. Listed as no longer reimbursed.
L3999	Upper limb orthosis, not otherwise specified	Not Covered	Codes without payment methodology by Medicare; more specific codes should be used. Listed as no longer reimbursed.

Replacement Rules

Prosthetic limb or custom orthotic brace — replacement as needed; confirmation if <3 years

Replacement policyProsthetic limb or custom orthotic brace: replacement is performed as needed (based on clinical condition or device failure).

When confirmation requiredIf the device or part being replaced is less than three years old, confirmation from the prescribing health care provider may be required.

Reasons for replacementChange in physiological condition of the patient; irreparable change in the device or part; or repair cost >60% of replacement cost.

Documentation Requirements

Documentation Required

Provide recent clinical notes when requesting prosthetic/orthotic replacements

When requesting prosthetic limb or custom orthotic brace replacements, submit the last 6 months of clinical notes from the requesting provider and/or specialist to support medical necessity.

Last 6 months of clinical notes from requesting provider and/or specialist

Note

Reference applicable DME policy for coverage details

Coverage for DME depends on meeting the criteria in the applicable policy statements listed above; providers should reference the specific DME policy for full details on documentation and clinical requirements.

Not Covered Items

The policy’s NOT COVERED section provides an extensive, itemized list of household, convenience, recreational, and other items that are not reimbursable as DME. Examples called out in the Applicable Codes lists include therapeutic lightboxes, whirlpools (portable and built-in), bathtub transfer benches and rails, exercise equipment (treadmills, stationary bikes), patient lifts not intended for home use, topical oxygen systems, certain assistive listening devices, oximeters and replacement probes (not covered for Medicare beneficiaries), wigs, and many other codes enumerated in the document. Providers should use these lists to confirm coverage and billing expectations.

Specifically, A7001 and A7002 are listed as not covered when used with a disposable external urine management system. The policy history documents that these and other items have been added to the non-covered list over time (for example, the addition of PureWick and Home Pulse Oximetry codes), and administrative updates note codes without Medicare payment methodology (e.g., L2999, L3999).

The not-covered lists include duplicate or overlapping entries in the Applicable Codes sections; providers should refer to the consolidated Non‑Covered/Not Medically Necessary lists within the policy for definitive billing guidance. Examples of repeated or cross-referenced non-covered items include oximeters and replacement probes, various transfer and bathing aids, and a range of assistive and comfort devices.

The policy’s NOT COVERED content is periodically updated (recorded in the revision history) and includes multiple specific entries that may appear in more than one Applicable Codes table or revision note. When discrepancies appear between tables, rely on the most recent policy text and revision history entries for coverage determination.

OpenPayer

Clinical Review Criteria — Durable Medical Equipment (DME): Device, Equipment and Supplies