CurrentMass General Brigham Health PlanPolicy 018

Durable Medical Equipment (DME) Medical Necessity and Coverage

Customize your policy alerts

Sign up for Mass General Brigham Health Plan Policy 018 alerts

Get alerted when Policy 018 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Guidelines for determining medical appropriateness and coverage of FDA-approved durable medical equipment, supplies, oxygen-related equipment, orthotics, hearing aids, and related items across applicable member programs.

Policy Summary

PayerMass General Brigham Health Plan

PolicyDurable Medical Equipment (DME)

Policy CodePolicy 018

Change TypeAdministrative/program-section update

Effective DateOctober 1, 2026

Last ReviewOct 1, 2026

Next Review DateNot specified

Key ActionSubmit DME prior-authorization requests through a Mass General Brigham Health Plan contracted DME provider.

SourceLink

POLICY UPDATE CHANGES

The October 2026 ad hoc review updated the ACO section.

RequiredPrior authorization

37InterQual DME categories

6 monthsTreating-provider order age

$1,000/yearBackup wheelchair repair limit

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentMass General Brigham Health PlanPolicy 018

Durable Medical Equipment (DME) Medical Necessity and Coverage

Customize your policy alerts

Sign up for Mass General Brigham Health Plan Policy 018 alerts

Get alerted when Policy 018 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerMass General Brigham Health Plan

PolicyDurable Medical Equipment (DME)

Policy CodePolicy 018

Change TypeAdministrative/program-section update

Effective DateOctober 1, 2026

Last ReviewOct 1, 2026

Next Review DateNot specified

Key ActionSubmit DME prior-authorization requests through a Mass General Brigham Health Plan contracted DME provider.

SourceLink

POLICY UPDATE CHANGES

The October 2026 ad hoc review updated the ACO section.

RequiredPrior authorization

37InterQual DME categories

6 monthsTreating-provider order age

$1,000/yearBackup wheelchair repair limit

Backup wheelchair repairs

Coverage Criteria

General DME coverage

Covered when the equipment is within the member's applicable benefit and all general DME requirements are satisfied.

General DME coverage: The requested DME is FDA-approved; medically necessary for treatment of illness or injury; intended to improve or stabilize the member's condition or improve functioning; able to withstand repeated use over time or is an essential medical supply for an approved DME item; and covered under the member's applicable benefit.

Plan materials determine individual benefit coverage.

General eligibility criteria

All of the following general eligibility criteria must be met.

General eligibility criteria: The item is not excluded; is durable or an essential medical supply; is appropriate for home use; does not duplicate existing DME without medical necessity; is part of an authorized home-care program when applicable; has no equivalent alternative that is at least as likely to produce equivalent therapeutic or diagnostic results; is the most appropriate least-intensive model; is within the manufacturer's weight and height limits; can be safely managed by the member; and, for a growing child, adjusts over time. The member must be motivated, adherent, understand the equipment's limitations, demonstrate proper care and use, and safely keep the equipment. Functional DME must be expected to produce improved or maintained function within a reasonable and predictable period.

For children, social and clinical supports and committed caregivers must support safe care, adherence, and maximum benefit.

DME under authorized home-health care

For DME ordered under an authorized home-health care plan, all applicable conditions must be met.

Home-health DME: The equipment is specifically related to the illness or injury requiring skilled home health care and is integral to the skilled home-health plan of care.

DME needed beyond the authorized plan of care, or received after the authorized care span and exceeding the member benefit, is the member's responsibility.

MassHealth backup power wheelchair repair

Repair coverage for a MassHealth member's serviceable retired backup power wheelchair requires all listed conditions.

Backup power wheelchair repair: The DME provider obtains prior authorization; the member's medical complexity prevents use of a manual wheelchair or suitable loaner power wheelchair while the primary mobility system is repaired; the repair cost does not exceed $1,000 per calendar year unless Mass General Brigham Health Plan determines that a more costly repair is cost-effective; only one serviceable backup power wheelchair is repaired per calendar year; and the wheelchair serial number and required documentation are submitted and retained in the member's file.$1,000 per calendar year; one wheelchair per calendar year

Prior authorization is required as a prerequisite for any repair.

General DME coverage criteria

DME is covered when all applicable criteria are met.

Home and equipment suitability: The equipment is appropriate for home use, is not duplicative, and satisfies any applicable home trial or evaluation requirements.
When applicable, the home evaluation should address access into and within the home, secure storage, maneuvering space, and operating surfaces.
Home-health connection: The equipment is not being requested under an authorized home-health plan, or it is specifically related to the illness or injury requiring skilled home health care and integral to the skilled plan of care.
Equipment beyond the authorized plan or date span may become the member's responsibility if it exceeds the member benefit.

Clinical and functional suitability

The requested DME must also satisfy all applicable clinical and functional criteria.

Clinical, functional, and user-capability criteria: There is no alternative service, sequence of services, device, or equipment at least as likely to produce equivalent therapeutic or diagnostic results; the requested item is the most appropriate, least-intensive model that meets the member's medical needs or supports activities of daily living; the member is within the manufacturer's weight and height limits; the member can safely and effectively manage the equipment; growing children have equipment or components that optimize adjustment over time; the member is motivated, expected to adhere, understands functional and physical limitations, and can demonstrate proper care, use, and safe keeping; and, for functional equipment, the member is expected to achieve or maintain improved function within a reasonable and predictable period.

When specific Mass General Brigham Health Plan or MassHealth criteria are unavailable, relevant CMS National or Local Coverage Determination criteria may be used if deemed relevant.

Pediatric equipment

For pediatric requests, all applicable pediatric criteria must be met.

Pediatric DME criteria: Social and clinical supports are in place for safe care and keeping of the equipment and maintaining adherence; caregivers are motivated and committed to maximizing the child's benefit; the equipment or its components are designed to accommodate growth; and the child is expected to be motivated, adherent, able to understand or demonstrate safe use as appropriate, and able to achieve the expected functional benefit.

Caregivers are responsible for day-to-day management of the equipment.

CPAP prior authorization is managed by CareCentrix rather than through this DME authorization process. Refer to the Treatment of Sleep Disordered Breathing in Adults and Children medical policy for additional information.

DME that serves a similar purpose as equipment already in use is excluded unless medical necessity supports an exception, such as a manual wheelchair backup for a power mobility system or an exception under applicable MassHealth requirements.

DME needed beyond an authorized home-health plan of care, or received after the authorized care span and exceeding the member's benefit, is the member's responsibility.

DME excluded by the member handbook or other plan documents is not covered. Equipment used solely for non-medical purposes or in the absence of illness or injury, including protective sports and recreation equipment, is also excluded.

Equipment must withstand repeated use over an extended period, or be an essential medical supply for the effective use of an approved DME item, such as oxygen tubing or a mask. Items that do not meet these requirements are excluded.

For Commercial and Qualified Health Plan members, coverage of power-operated vehicles or scooters used for community use only is excluded. Equipment appropriate for home use may also be used in the community.

Coverage is excluded for equipment used solely in a school program, duplicative DME, equipment for which an equivalent alternative is available, and a more intensive model when a less intensive model adequately meets the member's needs. Convenience, recreational or avocational, experimental or investigational, and non-FDA-approved equipment and features are also excluded.

Home-use functional electrical stimulation devices are excluded because current literature provides insufficient proof of long-term efficacy. Examples include the Bionicare Knee System, WalkAide, Odstock Dropped Foot Stimulator (ODFS) Pace, and FES bikes.

Myoelectric orthoses are excluded, including named examples such as Myomo and the Ottobock C-brace.

The policy does not cover routine periodic testing, cleaning, regulating, or checking of DME. It also excludes evaluation or diagnostic testing performed by the DME provider to establish the medical need for the equipment.

An item is not medically necessary when an alternative service, sequence of services, device, or equipment is at least as likely to produce equivalent therapeutic or diagnostic results for the member's illness, disease, or injury.

An item is not medically necessary when it is not the most appropriate, least-intensive model that adequately meets the member's medical needs or allows activities of daily living. A more intensive model is excluded when a less intensive model is adequate.

Functional DME is not medically necessary when the member is not expected to reach or maintain a predicted improved functional state within a reasonable and predictable period with use of the prescribed equipment.

Services that are not medically necessary are excluded, including scalp cooling caps used to prevent hair loss. Coverage may also be excluded when equipment will not improve or stabilize the member's condition or improve functioning.

Home-use functional electrical stimulation devices are considered not medically necessary because of insufficient proof of long-term efficacy in current literature. Listed examples include the Bionicare Knee System, WalkAide, Odstock Dropped Foot Stimulator (ODFS) Pace, and FES bikes.

Coding and Operational Limits

Medicare Advantage NCD Referencesmixed

NCD 280.1	Durable Medical Equipment Reference List
NCD 240.2	Home Use of Oxygen
NCD 280.7	Hospital Beds
NCD 280.15	INDEPENDENCE iBOT 4000 Mobility System
NCD 270.6	Infrared Therapy Devices
NCD 280.3	Mobility Assistive Equipment (MAE)
NCD 160.12	Neuromuscular Electrical Stimulation (NMES)
NCD 280.16	Seat Elevation Equipment (Power Operated) on Power Wheelchairs
NCD 280.4	Seat Lift

Medicare Advantage LCD Referencesmixed

L33686	Ankle-Foot/Knee-Ankle-Foot Orthosis
L33690	Automatic External Defibrillators
L36267	Bowel Management Devices
L33733	Canes and Crutches
L33823	Cervical Traction Devices
L33735	Cold Therapy
L33736	Commodes
L33317	External Breast Prostheses
L39591	External Upper Limb Tremor Stimulator Therapy
L33737	Eye Prostheses

1–10 of 45

1/5

Backup Power Wheelchair Repair Cost

Annual repair limitTotal repair cost does not exceed $1,000.00 per calendar year.

ExceptionMass General Brigham Health Plan may determine case by case that a more costly repair is a cost-effective solution for the member.

Applies toRepair of a serviceable backup power wheelchair for a MassHealth member.

Treating-Provider Order Age

Required documentA written order from the treating provider is required.

Signature and dateThe order must be signed and dated by the treating provider.

Provider Actions and Decision Points

Prior Authorization

Submit Through a Contracted DME Provider

Submit DME requests, including prior-authorization requests, through a Mass General Brigham Health Plan contracted DME provider.

Prior authorization may be required for DME, supplies, oxygen-related equipment, orthotics, and hearing aids; consult the DME Prior Authorization List.

Note

Medicare Advantage Criteria Hierarchy

For Medicare Advantage members, apply CMS guidance first. Use applicable NCDs, LCDs, LCAs, and Medicare-manual documentation; use Mass General Brigham Health Plan medical policies only when CMS has no applicable guidance.

Confirm the applicable CMS coverage determination for the requested DME category.
The policy lists CMS guidance for DME, oxygen, hospital beds, mobility equipment, NMES, seat elevation, orthoses, respiratory equipment, wheelchairs, and other categories.

Policy Background

This policy addresses coverage of FDA-approved durable medical equipment that is medically necessary to treat illness or injury, improve or stabilize the member's condition, or improve functioning. Covered equipment must generally withstand repeated use, be appropriate for use in the home, be safely manageable by the member, and be expected to provide therapeutic, diagnostic, or functional benefit, subject to the member's applicable benefit and program-specific criteria.

Definitions

Durable Medical Equipment

ApprovalFDA-approved equipment.

Medical purposeEquipment medically necessary for treatment of illness or injury.

Expected benefitEquipment that improves or stabilizes the member's condition or improves functioning.

DurabilityEquipment that can withstand repeated use over time.

Benefit coverageEquipment within the member's applicable benefit.

Home-Use DME

Home suitabilityEquipment appropriate for use in the member's home.

Medical Necessity Requirements

General DME medical necessity

DME must meet all general eligibility and safety requirements.

DME medical necessity: The item is covered under the member's benefit, medically necessary, appropriate for home use, durable or an essential medical supply, nonduplicative, safe and manageable, within manufacturer limits, and expected to produce therapeutic, diagnostic, or functional benefit. The member must be motivated and adherent, able to understand and safely use and maintain the equipment, and expected to achieve improved or maintained function when the DME is intended to provide function.

Apply equipment-specific criteria in the applicable Mass General Brigham Health Plan policy, InterQual criteria, CMS criteria, MassHealth guidance, or plan documents.

DME medical necessity

DME must meet all applicable general, home-use, clinical, functional, and user-capability criteria.

DME suitability: The equipment is durable, medically useful, appropriate for home use, not duplicative, not more intensive than necessary, within manufacturer limits, safely manageable, and expected to improve or maintain function or provide equivalent therapeutic or diagnostic benefit when no adequate alternative exists.

Rental and Purchase Rules

Equipment	Rule	Details
DME generally	Rental	Mass General Brigham Health Plan determines whether it is appropriate to rent the equipment for the member.

Equipment	Rule	Details
DME generally	Purchase	Mass General Brigham Health Plan determines whether it is appropriate to purchase the equipment for the member. Replacement parts and repairs are covered when the DME is no longer under warranty.

Replacement and Repair

DME and DME Parts

Equipment coveredDME and DME parts.

Useful lifetimeFive years.

Replacement ruleReplacement is generally excluded when the equipment has not surpassed a reasonable useful lifetime of five years.

Repair ruleRepair is generally excluded when the equipment has not surpassed a reasonable useful lifetime of five years.

Required Documentation

Documentation Required

Complete the documentation package

Submit complete clinical, prescription, and item-specific documentation with the request, including the signed and dated treating-provider order, current treating-provider signature and NPI dated within six months, clinical condition, abilities, limitations, prior treatment and outcomes, item-specific justification, expected benefit, equipment details, quantity, settings, duration, and order start date.

Documentation Required

Document home fit and usability

When applicable, provide a home trial or evaluation by an assistive-technology-certified provider documenting usability, physical fit, entry and room access, maneuvering space, operating surfaces, and secure storage.

Documentation Required

Document backup wheelchair repair

For a repaired serviceable retired backup power wheelchair, document the serial number, submit the required MassHealth documentation, and retain all documentation in the member’s file.

Not Covered

Not covered are items excluded by plan documents; equipment used for non-medical, recreational, avocational, school-only, convenience, experimental, or investigational purposes; non-FDA-approved or duplicative equipment; equipment not appropriate for home use; community-use-only scooters for Commercial and Qualified Health Plan members; home or vehicle modifications; and listed convenience features, accessories, FES devices, and myoelectric orthoses. Routine DME testing, cleaning, regulating, checking, and provider diagnostic testing to establish medical need are also excluded. Replacement or repair may be excluded when the item is under warranty, has not exceeded a five-year reasonable useful lifetime, was lost or damaged through improper care, or repair costs are at least the cost of replacement.

Policy Summary

PayerMass General Brigham Health Plan

PolicyDurable Medical Equipment (DME)

Policy CodePolicy 018

Change TypeAdministrative/program-section update

Effective DateOctober 1, 2026

Last ReviewOct 1, 2026

Next Review DateNot specified

Key ActionSubmit DME prior-authorization requests through a Mass General Brigham Health Plan contracted DME provider.

SourceLink

On This Page

TimingThe treating provider's signature date must be within 6 months of the request.

Backup Power Wheelchair Repair Frequency

Annual quantity limitMass General Brigham Health Plan will pay for the repair of only one serviceable backup power wheelchair per calendar year.

Equipment typeThe limit applies to a serviceable retired backup power wheelchair.

Member programThis requirement applies to MassHealth members.

Treating-Provider Order Timing

Order statusThe treating provider's order must be signed and dated.

Order timingThe order must be issued within six months of the request.

Applicable equipmentThis timing requirement applies to DME requests under the Commercial and Qualified Health Plans criteria.

Reasonable Useful Lifetime

Reasonable useful lifetimeFive years.

ReplacementReplacement is generally excluded when the equipment has not surpassed a reasonable useful lifetime of five years.

RepairRepair is generally excluded when the equipment has not surpassed a reasonable useful lifetime of five years.

Note

Medicaid and Integrated-Plan Criteria Hierarchy

For Mass General Brigham ACO members, use MassHealth guidance first. If MassHealth has no applicable guidance, use the relevant Medicare Advantage LCD; if no LCD applies, use the Commercial and Qualified Health Plans criteria.

Review MassHealth provider regulations, provider manuals, and Guidelines for Medical Necessity Determination.
For One Care and SCO members, apply Medicare Advantage criteria first; if those criteria are not met, apply MassHealth criteria.

Unsupported block type: documentation

Unsupported block type: prior_auth

Documentation Required

Provide Clinical and Equipment Justification

Document why the specific DME is medically necessary and how it will improve or stabilize the member’s condition or improve functioning. The request must describe the member’s condition, abilities, limitations, prior treatment and outcomes, and the expected therapeutic benefit.

Compare the requested item with similar equipment and explain why it is appropriate.
Identify the brand, model number, separately billed accessories and options, quantity, refills, settings, hours of use, additional features, expected duration, and order start date.
The item must be FDA-approved, withstand repeated use over time, and fall within the member’s applicable benefit.

Documentation Required

Obtain a Current Treating-Provider Order

Include a written order signed and dated by the treating provider. A request may be prepared by another person, but the treating provider must review, sign, and date it before submission.

The ordering provider may be a physician, nurse practitioner, or physician assistant.
Include the current treating provider’s signature and NPI; the signature date must be within six months of the request.
The signed and dated treating-provider order must be within six months of the request.

Documentation Required

Document Home Trial and Environmental Fit

When applicable, obtain a home trial or evaluation by a provider certified in assistive technology. The evaluation must attest that the equipment is usable and physically fits in the member’s home.

Document adequate entry into the home, access between rooms, maneuvering space, operating surfaces, and secure storage.
For power mobility and other applicable equipment, address the home environment before submitting the request.

Unsupported block type: documentation

Documentation Required

Current Order Required

Ensure the current treating provider’s order is signed and dated, includes the provider’s NPI, and is dated within six months before the request.

The order must identify the requested DME and support the medical-necessity request.

Documentation Required

Evaluate Home Access and Safety

For applicable DME, document that the item fits and can be safely used in the member’s home, including access, storage, maneuvering space, room-to-room travel, and appropriate operating surfaces.

A home trial or evaluation should address entry into the home and secure storage.
Community use may be appropriate when the DME is appropriate for home use.

Documentation Required

Tie DME to the Authorized Home-Health Plan

DME provided under an authorized home-health plan must be specifically related to the illness or injury requiring skilled home health care and integral to the authorized plan of care.

Equipment beyond the authorized plan, after the authorized date span, or exceeding the member benefit may be the member’s responsibility.
Confirm the requested item is included in the applicable Mass General Brigham Health Plan home-health plan.

Documentation Required

Document Pediatric Support and Caregiver Readiness

For a child, document the social and clinical supports needed for proper care, safe keeping, and adherence. Caregivers must be motivated and committed to helping the child obtain the maximum benefit.

For growing children, show that the equipment or components can be adjusted to optimize use over time.

Documentation Required

Confirm Safe Use and Adherence

Document that the member can safely manage the equipment, understands its functional and physical limits, can demonstrate proper care and use, and is expected to adhere to treatment.

Address the member’s ability to manage equipment weight, stability, and power.
Document motivation, expected adherence, and ability to gain maximum benefit.

Documentation Required

Provide Proof for Stolen or Damaged Equipment

For equipment reported stolen or damaged through improper care, misuse, or neglect, the plan may require proof before considering replacement or repair.

Potential proof includes a police report, photographs, or a corroborating statement.

Denial Risk

Check Benefit, Approval, and Necessity

DME may be denied when it is excluded by the member handbook or other plan documents, lacks required approval, is not medically necessary, or does not improve or stabilize the member’s condition or functioning.

Confirm the requested item is within the member’s benefit and is FDA-approved.
Do not assume an order alone establishes coverage; applicable plan criteria and prior authorization requirements must also be met.

Denial Risk

Meet General DME Requirements

A request may be denied when the equipment fails the general DME requirements, including repeated-use durability, home appropriateness, nonduplication, plan authorization, or the member’s ability to use it safely and effectively.

Confirm the item is not serving the same purpose as existing DME, unless an applicable backup-wheelchair exception applies.
Confirm it is the most appropriate, least intensive model that meets medical needs or supports activities of daily living.

Denial Risk

Address Equivalent Alternatives

Coverage may be denied when another service, sequence of services, device, or equipment is at least as likely to produce equivalent therapeutic or diagnostic results for the member’s illness, disease, or injury.

Compare alternatives in the clinical documentation and explain why the requested DME is superior or otherwise necessary.
Do not request duplicative equipment unless medical necessity supports an applicable exception.

Denial Risk

Confirm Safe and Compatible Use

The requested DME must be safe and compatible for the member. Denial risk increases when the member exceeds manufacturer weight or height limits or cannot safely manage the equipment’s weight, stability, or power.

Document applicable weight, height, functional, strength, stability, and compatibility considerations.

Denial Risk

Show Expected Functional Benefit

For DME prescribed to improve function, document that the member is expected to reach or maintain a predicted improved functional state within a reasonable and predictable period.

Explain the expected functional improvement and therapeutic outcome.
Requests may be denied when the item is suboptimal or is not expected to improve or stabilize the member’s condition or functioning.

Denial Risk

Avoid Home-Health Plan Limitations

DME ordered during an authorized home-health plan must be related to the illness or injury requiring skilled care and integral to that plan. Equipment outside the authorized plan or date span may not be covered.

Verify the item is included in the authorized plan of care and does not exceed the member’s benefit.

Prior Authorization

Backup Power Wheelchair Repair Limits

Backup power wheelchair repairs for MassHealth members require prior authorization and are subject to cost and frequency limits.

The repair generally may not exceed $1,000 per calendar year; a more costly repair may be approved case by case when cost-effective.
Only one serviceable backup power wheelchair repair is covered per calendar year.
The member must be unable to use a manual wheelchair or suitable loaner power wheelchair because of medical complexity.

Denial Risk

Meet General Medical Necessity Criteria

The member must meet the plan’s general medical-necessity criteria, including appropriate equipment selection, expected benefit, safe use, motivation, adherence, and understanding of care and limitations.

The item must be the least intensive appropriate model and must support medical needs or activities of daily living.
Document predicted functional improvement, safe management, proper care, and expected adherence.

Denial Risk

Identify Excluded Uses and Equipment

The plan excludes DME used solely for nonmedical, recreational, avocational, school-only, or convenience purposes, as well as equipment that is experimental, investigational, not FDA-approved, or otherwise excluded by plan documents.

Community-only scooters are excluded for Commercial and Qualified Health Plan members.
Home or vehicle modifications, furniture supporting covered DME, and equipment that does not improve or stabilize the condition may be excluded.

Denial Risk

Separate Convenience Features and Accessories

Features and accessories principally used for convenience or providing a non-medically necessary attribute are not covered. Certain battery types and other convenience items are specifically excluded.

Standard off-the-shelf batteries are excluded except when used for and billed specifically with insulin pumps or continuous glucose monitors.
Nonsealed batteries for power mobility devices or wheelchairs are excluded.
Examples of excluded items include exercise or massage devices, air conditioners, dehumidifiers, whirlpools, speed upgrades, and certain shoes or foot supports.

Denial Risk

Recognize Excluded FES and Myoelectric Devices

Functional electrical stimulation devices for home use and myoelectric orthoses are excluded because they are considered not medically necessary or specifically noncovered under the policy.

Examples of excluded FES devices include Bionicare Knee System, WalkAide, Odstock Dropped Foot Stimulator (ODFS) Pace, and FES bikes.
Examples of excluded myoelectric orthoses include Myomo and Ottobock C-brace.

Denial Risk

Apply Replacement and Repair Limits

Replacement or repair may be denied when the equipment is under warranty, has not exceeded a reasonable five-year useful life, is lost or damaged through improper care, or can be replaced more economically.

Replacement may be denied when the member has a functioning model and an upgrade is not medically necessary.
Repair may be denied when its cost equals or exceeds the cost of replacement.
Routine testing, cleaning, regulating, checking, or DME-provider diagnostic evaluations to establish need are not covered.

Community useEquipment appropriate for home use may also be used in the community.

Coverage contextThe equipment must be appropriate for use in a home setting.

Serviceable Retired Backup Power Wheelchair

EquipmentA power wheelchair retained for backup use.

ServiceabilityThe wheelchair remains serviceable.

Primary system contextThe primary mobility system requires repair.

Accessories

PurposeProducts fabricated primarily and customarily to modify or enhance the usefulness or functional capability of another piece of equipment.

Relationship to equipmentAccessories are associated with another piece of equipment.

Independent usefulnessAccessories are generally not useful in the absence of that other piece of equipment.

Customized Equipment

ConstructionDurable medical equipment uniquely constructed, adapted, or modified solely for the full-time use of the patient for whom it is purchased.

Patient-specific designThe equipment is made-to-order or adapted to meet the specific needs of the patient.

Use by othersThe unique construction, adaptation, or modification permanently precludes use by another individual.

Durable Medical Equipment

DurabilityEquipment that can withstand repeated use.

Primary purposeEquipment primarily and customarily used to serve a medical purpose.

Medical necessity contextEquipment generally not useful to a person in the absence of an illness or injury.

Home suitabilityEquipment appropriate for home use.

Principal locationEquipment principally for use in the home.

Home Setting

Basic definitionAny place where the member has established a place of residence while home care services are being provided.

ExamplesA dwelling, apartment, friend or family member's home, group home, homeless shelter, temporary place of residency, or community setting.

Excluded settingsHospitals, skilled nursing facilities, intermediate care facilities for the developmentally disabled, and other institutional facilities providing medical, nursing, rehabilitative, or related care.

Day-care settingsA day care, adult day care, or adult medical care setting does not meet the definition of a home setting.

Mobility System

Included devicesA manual or power wheelchair or another wheeled device, such as a scooter.

Base and seatingThe system includes a base and seating system.

Additional componentsThe system includes its components, accessories, and modifications.

Seating Systems

System typeA seated positioning system.

Included elementsThe system includes its components, accessories, and modifications.

Wheelchair attachmentThe system may be attached to a base wheelchair.

Medical purposeThe system is designed to meet the individualized medical needs of the patient.

Used Equipment

Basic definitionAn item that has been previously purchased or rented.

Patient trialEquipment used by a patient for a trial period.

Supplier demonstratorEquipment used by the supplier as a demonstrator.

Rental-to-purchaseEquipment rented by a patient who now wants to buy it.

The member must be able to use, care for, and safely keep the equipment and is expected to adhere to its use.

Documentation Required

Submit a current provider order

The treating provider’s order must be signed and dated and issued within six months of the request.

Documentation Required

Evaluate home access and usability

For applicable equipment, particularly power mobility devices, document home access, secure storage, access between rooms, maneuvering space, and operating surfaces through a home trial or home-environment evaluation.

Documentation Required

Document pediatric support and growth needs

For children, document caregiver and social or clinical support, motivation, safe keeping, adherence support, equipment adjustability for growth, and expected benefit.

Documentation Required

Provide evidence of theft or damage

For stolen or damaged equipment, the plan may require evidence supporting the report.

Acceptable supporting evidence may include a police report, pictures, or a corroborating statement.