ModifiedMass General Brigham Health PlanPolicy 018

Durable Medical Equipment (DME) coverage

Defines Mass General Brigham Health Plan criteria for medical necessity, prior authorization, exclusions, and variations for Durable Medical Equipment (DME) across commercial, Medicare Advantage, MassHealth, OneCare and SCO members; applies to providers submitting DME requests through contracted DME suppliers.

Policy Summary

PayerMass General Brigham Health Plan

PolicyDurable Medical Equipment (DME) coverage

Policy CodePolicy 018

Change TypeMaterial revisions and additions (prior auth table, Medicare/MassHealth variations, exclusions)

Effective Date

Next Review Date

Key ActionSubmit prior authorization requests through a contracted DME provider and include a treating provider's signed and dated order (within 6 months) plus required clinical documentation and device details.

SourceLink

POLICY UPDATE CHANGES

Updated prior authorization table and list of related policies; added variation for OneCare and SCO members and note that CareCentrix manages prior authorization for CPAP machines.

Updated Medicare variation and added LCDs.

Added MassHealth variation language and clarified exclusions to include scalp cooling caps.

29DME categories with InterQual criteria listed

11General coverage criteria points required for DME coverage

18Exclusion list items and examples

5 yearsReplacement interval (years)

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Coverage Criteria

General DME medical necessity

Covered when ALL of the following are met:

General Eligibility Coverage Criteria: 1) Item is FDA-approved DME medically necessary to improve or stabilize the member's condition or to improve functioning; 2) Item can withstand repeated use over an extended period of time or is an essential medical supply for an approved DME (e.g., oxygen tubing or mask); 3) Item is appropriate for use in a home setting; 4) If applicable (e.g., power mobility), documentation of a home trial/evaluation attests to fit and access in the home (access, storage, maneuvering space, surfaces); 5) Item is not serving a similar purpose as other DME already in use unless medical necessity supports both (e.g., manual backup to a power mobility system) and any applicable MassHealth rules apply; 6) Item is part of an authorized home care program when ordered during home-health care and is specifically related and integral to the skilled plan of care; 7) No alternative service, sequence of services, device, or equipment is at least as likely to produce equivalent therapeutic or diagnostic results; 8) Requested DME is the most appropriate, least intensive model that adequately meets the member's medical needs and activities of daily living; 9) Member does not exceed manufacturer's recommended weight or height restrictions; 10) Requested DME can be safely and effectively managed by the member (weight, stability, power); 11) For children who are still growing, requested DME or components are designed to accommodate growth; 12) Member is highly motivated and able to gain maximum benefit; 13) Member is expected to reach or maintain an improved functional state within a reasonable and predictable period of time with prescribed DME; 14) Member is expected to be highly adherent to use of the DME; 15) Member understands functional and physical limits of the DME and can demonstrate proper care, use, and safe keeping of the DME; 16) Signed and dated treating provider order must be within six months of the request and include required clinical documentation to support medical necessity.

See chunks 3,8,9 for full criteria

Items requiring InterQual criteria

InterQual-based items

InterQual-specified DME: Medical necessity for the enumerated DME items is determined using InterQual® criteria. Providers must consult InterQual via the plan provider website for item-specific rules and documentation requirements.

Includes items such as: Bone growth stimulators (noninvasive); Wearable cardioverter defibrillator (WCD); Continuous glucose monitors; Hearing aids; Home oxygen; Hospital beds; Negative pressure wound therapy pumps; Noninvasive airway assistive devices; and other InterQual-listed categories.

Items are excluded from coverage when they meet any of the following: the item is excluded in the member handbook or other plan documents; it is provided solely for non-medical purposes or in the absence of illness or injury (for example protective sporting equipment); the service or item is not medically necessary (for example, scalp cooling caps used to prevent hair loss); the item will not improve or stabilize the member's condition or functioning or is suboptimal compared to other acceptable options; the item cannot withstand repeated use or is not an essential medical supply for an approved DME item; the item is solely for school use; the item duplicates other DME serving the same purpose (unless medically supported, e.g., a manual wheelchair back-up to a power mobility system under certain circumstances); there is an alternative service/device at least as likely to produce equivalent results; or there is a more appropriate, less intensive model that adequately meets the member's medical needs.

The policy clarifies that exclusions include devices provided to prevent hair loss; specifically, scalp cooling caps are listed as not medically necessary and are excluded from coverage.

Equipment that the plan determines to be non-medical in nature and used primarily for non-medical purposes will not be considered DME and may be denied. The policy reiterates that DME must primarily serve a medical purpose, be appropriate for home use, and generally be not useful in the absence of illness or injury.

Functional electrical stimulation (FES) devices for home use are considered not medically necessary due to insufficient evidence of long-term efficacy. Examples specifically cited include the Bionicare Knee System, WalkAide, Odstock Dropped Foot Stimulator (ODFS) Pace, and FES bikes.

Coding

DME items governed by InterQualmixed

InterQual list

InterQual® criteria apply for enumerated DME categories (e.g., Bone Growth Stimulators, WCD, CGMs, Hearing Aids, Home Oxygen, Hospital Beds, NPWT, Noninvasive Airway Assistive Devices, etc.)

Provider Actions & Authorization

Prior Authorization

Prior Authorization Required for Certain DME

Prior authorization is required for certain DME items. See the Mass General Brigham Health Plan DME Prior Authorization List for details on items that require authorization across Commercial, Qualified Health Plans, Mass General Brigham ACO, Medicare Advantage, OneCare, and Senior Care Options (SCO) products. Where applicable, prior authorization requirements and plan variations (e.g., Medicare, OneCare, SCO) are reflected in the plan-specific prior authorization table.

DME Prior Authorization List: includes medical supplies, oxygen-related equipment, orthotics, hearing aids, and other listed items.
CareCentrix manages prior authorization for CPAP machines (noted in the January 2026 update).
Variations for OneCare and SCO members are noted in the prior authorization table.

Documentation Required

Prior Authorization Documentation Required

Prior authorization requests must include complete documentation to avoid denials. Requests should be submitted through a Mass General Brigham Health Plan contracted DME provider and must contain the treating provider's signed and dated order, provider identifiers, and clinical justification.

Medical Necessity Criteria

General DME medical necessity

General DME medical necessity criteria (applies across equipment types)

DME medical necessity nodes: See coverage criteria nodes: Item is FDA-approved and medically necessary to improve or stabilize condition or function; item can withstand repeated use or is an essential supply for approved DME; appropriate for home use; home trial/evaluation documented when applicable; not duplicative of other DME unless medically supported; part of authorized home care when ordered during home-health care; no alternative likely to produce equivalent results; least intensive appropriate model chosen; within manufacturer weight/height limits; manageable by member; pediatric devices accommodate growth; member motivation and adherence expected; treating provider order signed within six months of request with required clinical documentation.

Rental and Purchase Rules

Item	Rule
General DME
Mass General Brigham Health Plan determines whether purchase or rental is appropriate; coverage includes purchase or rental, and replacement parts and repairs when the DME is no longer under warranty. Prior authorization requests should be submitted through a contracted DME provider and must include required documentation (see documentation requirements).

Item	Rule / Management
Used equipment
Defined as any item previously purchased or rented, including trial-use items, demonstrators, or rented items a patient now wishes to buy; treated as purchase when applicable and subject to plan review.
CPAP machines
Prior authorization for CPAP machines is managed by a third party (CareCentrix) per the updated prior authorization table and management notes; prior authorization requirements and any plan-specific variations (e.g., OneCare, SCO, MassHealth) apply.

Replacement and Useful Lifetime

DME generally — Replacement / repair threshold

Reasonable useful lifetimeFive years — replacement or repair not covered if item has not surpassed a reasonable useful lifetime of five years.

Warranty exclusionNot covered if item is still under manufacturer warranty.

Loss or damage exclusionsNot covered if lost, stolen, or damaged due to improper care, misuse, or neglect (proof may be required).

Serviceable backup power wheelchair (MassHealth members)

MassHealth prior authorizationRepair of a serviceable retired backup power wheelchair requires prior authorization from MassHealth or its designee.

Medical complexity requirementMember must be unable to use a manual wheelchair or suitable loaner power wheelchair due to medical complexity.

Documentation Requirements

Documentation Required

Document home trial/evaluation for fit and usability

When a DME item (e.g., power mobility) requires fit assessment, include documentation of a home trial/evaluation performed by a provider with certification in assistive technology attesting to device usability and physical fit in the member's home.

Home trial documentation must address access into the home, access between rooms, maneuvering space, and surface suitability for operation and storage.

Documentation Required

Submit complete device description and treatment history

Provide a detailed device description (brand, model, accessories/options), quantity, number of refills (if applicable), equipment settings/hours of use, start date, length of need, and a summary of prior treatments and outcomes in the prior authorization submission.

Include medical justification comparing similar equipment and expected therapeutic benefit.
Specify any accessories or options that will be billed separately.

Definitions

Accessories

DefinitionProducts fabricated primarily and customarily to modify or enhance the usefulness or functional capability of another piece of equipment and generally not useful in the absence of that other piece of equipment.

Relationship to primary deviceAccessories are dependent on and intended to be used with a primary piece of equipment; they are not usually useful standalone.

Coverage implicationAccessories are considered in the context of the associated DME and may be excluded if deemed convenience items or non-medical.

Customized Equipment

DefinitionDurable medical equipment uniquely constructed, adapted, or modified solely for the full-time use of the patient; made-to-order or adapted to meet specific patient needs; unique modifications permanently preclude use by another individual.

Construction

Not Covered / Exclusions

Mass General Brigham Health Plan does not cover certain items including home or vehicle modifications (ramps, elevators, stair lifts), equipment primarily for recreational or avocational use, items that are not FDA approved, and furniture or other non-medical items used to support DME. These are explicitly listed as not covered in the exclusions section.

Equipment determined by the plan to be non-medical in nature and used primarily for non-medical purposes is not considered DME and therefore is not covered. In addition, the policy explicitly clarifies that scalp cooling caps are excluded as not medically necessary.

The policy lists multiple categories of items that are not covered, reiterating that items lacking medical necessity, items that cannot withstand repeated use, experimental/investigational items, and non-FDA-approved devices are excluded. The exclusions section also emphasizes denial potential for items used primarily for non-medical purposes and again names scalp cooling caps among non-covered services.

Background

Durable Medical Equipment (DME) is equipment that can withstand repeated use, primarily serves a medical purpose, is generally not useful in the absence of illness or injury, and is appropriate for and principally for use in the home. Medical necessity determinations for DME follow the policys general coverage criteria and, for many items, are governed by InterQual criteria; documentation (including a treating provider order signed and dated within six months) is required to support coverage requests.

Policy Summary

PayerMass General Brigham Health Plan

PolicyDurable Medical Equipment (DME) coverage

Policy CodePolicy 018

Change TypeMaterial revisions and additions (prior auth table, Medicare/MassHealth variations, exclusions)

Effective Date

Next Review Date

SourceLink

On This Page

A written order signed and dated by the treating provider (physician, nurse practitioner, or physician assistant). If prepared by someone else, the treating provider must review, sign, and date before submission.
Treating provider's signature and NPI number with a signature date within six months of the request.
Description of the member’s condition, abilities, limitations, and factors contributing to the need for DME.
Summary of prior treatment plans and outcomes.
Medical justification for the specific item(s), including comparison to similar equipment and expected therapeutic benefit.
Detailed DME description: brand, model numbers, accessories/options billed separately.
Quantity, number of refills (if appropriate), equipment settings, daily hours of use, and expected duration of need (how long member will need the DME).
Start date of the order.
If applicable, documentation of a home trial/evaluation by a qualified assistive-technology provider attesting to device usability and physical fit in the member's home (access, maneuvering space, storage).

Denial Risk

Coverage Rule Violations and Denial Risks

To avoid denials, ensure requests meet coverage criteria and do not violate exclusions or coverage rules. Denials may result if items are excluded by plan documents, are non-medical in nature, duplicate existing DME, are not appropriate for home use, or if a less intensive/alternative service would be equally effective.

Item is excluded in the member handbook or other plan documents.
Item is primarily for non-medical purposes or used in the absence of illness or injury (e.g., sports protective equipment).
Services or items that are not medically necessary or will not improve/stabilize the member's condition.
Item cannot withstand repeated use or is not essential for the effective use of approved DME (e.g., non-durable supplies when not covered).
Item duplicates other DME already in use by the member without documented medical necessity for duplication.
A more appropriate, less intensive model or alternative service exists that would produce equivalent therapeutic results.
Certain convenience features or non-medically necessary accessories (e.g., standard batteries, unsealed batteries for mobility devices, exercise/massage equipment, air conditioners) are excluded.

Prior Authorization

Least Intensive Appropriate Device Requirement

DME must be the most appropriate, least intensive medically necessary model that adequately meets the member's needs. When multiple devices or services are available, the requested DME should be no more intensive than required to achieve the therapeutic goal and activities of daily living.

Request must show there is not an alternative service, sequence of services, device, or equipment at least as likely to produce equivalent results.
If a less intensive model adequately meets medical needs, the less intensive option is preferred.
Power mobility systems: manual wheelchair back-up to a power system may be allowed when medically necessary and where MassHealth regulations apply.

Note

Supporting References

Supporting references and external criteria that may be used to determine medical necessity and coverage decisions are listed below. Providers may be required to reference these materials when submitting prior authorization requests.

InterQual® criteria: access via Mass General Brigham Health Plan provider website (InterQual® Criteria Lookup). Applicable to listed DME items such as bone growth stimulators, wearable cardioverter defibrillators, continuous glucose monitors, hearing aids, home oxygen, hospital beds, NPWT pumps, noninvasive airway assistive devices.
MassHealth Provider Manuals and MassHealth Guidelines for Medical Necessity Determination.
CMS Local Coverage Determinations (LCDs) for DME and CMS National Coverage Determination for Durable Medical Equipment Reference List.
Policy revision history summarizes prior authorization and criteria updates (see policy Effective/Revision notes).

Annual repair limitTotal repair cost must not exceed $1,000 per calendar year unless Mass General Brigham Health Plan determines a higher cost is cost-effective on a case-by-case basis.

One-per-year repairPlan will pay for repair of only one serviceable backup power wheelchair per calendar year.

Note

Use cited manuals/guidelines to support documentation

Policy references such as MassHealth provider manuals and MassHealth medical necessity guidelines are cited and may be required to support coverage determinations and documentation.

Use the cited MassHealth resources and CMS LCD/NCD references when applicable to support PA decisions.

Includes made-to-order items or equipment adapted to meet the patient’s specific needs.

ExclusivityUnique construction or modification permanently prevents reuse by another individual.

Durable Medical Equipment (DME)

DefinitionEquipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally not useful absent illness or injury, and is appropriate and principally for home use.

Home appropriatenessDME must be appropriate for use in the home and principally intended for home use.

Non-medical exclusionEquipment determined to be non-medical in nature and used primarily for non-medical purposes will not be considered DME.

Customized Equipment (duplicate entry)

DefinitionDurable medical equipment uniquely constructed, adapted, or modified solely for the full-time use of the patient; made-to-order or adapted to meet specific needs; modifications permanently preclude use by another individual.

Patient-specific designCustomized equipment is intended solely for the individual for whom it is constructed or adapted.

Coverage considerationBecause modifications preclude reuse, these items are treated differently from standard DME in assessment and reimbursement.

Durable medical equipment (DME) (duplicate entry)

DefinitionEquipment which can withstand repeated use, primarily serves a medical purpose, is generally not useful absent illness or injury, and is appropriate for home use and principally for the home setting.

Non-medical determinationItems determined by the plan to be non-medical in nature and used primarily for non-medical purposes are excluded from DME.

Examples stated elsewhereSee exclusions for items not considered DME (e.g., certain recreational or convenience features).

Home Setting

Definition of home settingAny place where the member has established residence for the time period when home care services are provided (includes dwellings, apartments, group homes, shelters, temporary residences, community settings).

Institutional exclusionsDoes not include hospitals, skilled nursing facilities, intermediate care facilities, or other institutional facilities providing medical/nursing/rehabilitative care.

Day programs exclusionDay care settings, adult day care, or adult medical care do not meet the home setting definition.

Mobility System / Seating Systems

Mobility system definitionA manual or power wheelchair or other wheeled device, such as a scooter, including the base, seating system, components, accessories, and modifications.

Seating systemsSeating systems are seated positioning systems, including components, accessories, and modifications, designed to meet individualized medical needs and may attach to a wheelchair base.

ScopeIncludes both the mobility base and associated seating and accessory components as part of the mobility system.

Used Equipment

DefinitionAny item previously purchased or rented, including equipment used for a trial period, demonstrator units, or rented items that a patient now wishes to buy.

Purchase implicationsUsed equipment is treated as previously owned and may be subject to purchase rules and prior authorization procedures per plan policy.

ExamplesIncludes trial-use items, supplier demonstrators, and rented equipment converted to purchase.