CurrentMississippi Division of MedicaidPolicy N/A

Durable Medical Equipment, Medical Appliances and Medical Supplies (DMEPOS)

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Governs provider participation, enrollment, definitions, reimbursement, warranties, rentals, repairs, and prior authorization requirements for DME, medical appliances, and medical supplies for Mississippi Medicaid beneficiaries; applies to DME suppliers participating in the Mississippi Division of Medicaid program.

Policy Summary

PayerMississippi Division of Medicaid

PolicyDurable Medical Equipment, Medical Appliances and Medical Supplies (DMEPOS)

Policy CodePolicy N/A

Change TypeMinor / Administrative (no material coverage changes)

Effective DateAug 1, 2026

Last ReviewJan 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization before or within 30 days of delivery for items requiring medical necessity review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30prior authorization timeframe (days)

1standard warranty (years)

2power wheelchair major components warranty (years)

10max rental months before ownership

5replacement interval (years)

80%/10%/50%reimbursement benchmarks (purchased/rental/used)

Policy summary and key facts

Coverage and Reimbursement Criteria

ScopeApplies to DME suppliers participating in Mississippi Medicaid and governs orders, prior authorization, warranties, rental-to-purchase, repairs, manual pricing and reimbursement for DME, medical appliances and medical supplies.

Order requirementDME must be ordered by an enrolled physician or an allowed non-physician practitioner within scope/collaborative agreement.

Prior authorization timingPrior authorization must be submitted prior to or within 30 days of delivery; beneficiary cannot be billed if provider delivers before approval and approval is not given.

Rental-to-purchase ruleRental reimbursed up to ten (10) months or up to purchase price, whichever is less; after ten months DME becomes property of beneficiary unless otherwise authorized.

Warranty and repairsStandard DME requires minimum 1-year manufacturer warranty; custom motorized/power wheelchair major components require 2-year warranty; providers responsible for repairs if no warranty.

Manual pricingItems without assigned fee are manually priced by UM/QIO/DOM using documentation and hierarchy (MSRP minus 20% then provider invoice plus 20%); invoices must be current (generally ≤1 year).

Fee determination

Primary fee sourceDivision uses Medicare DMEPOS fee schedule as basis; providers reimbursed at Division's allowable fee when assigned.

Manual pricing triggerItems without an assigned allowable fee will be manually priced by UM/QIO, DOM or designated entity.

Manual pricing hierarchyIf no fee, use MSRP minus 20% (supported by manufacturer's documentation); if no MSRP, use provider invoice plus 20%; invoices must not be older than 1 year except unusual circumstances.

Coverage criteria for DME, appliances, and supplies

DME coverage and reimbursement criteria — general rules

Coverage and reimbursement are conditional on an appropriate order, prior authorization and compliance with warranty, rental-to-purchase, repair and manual pricing rules.

DME must be ordered by a physician or an allowed non-physician within scope/collaborative agreement.

Prior authorization must be submitted prior to or within thirty (30) days of delivery; beneficiary cannot be billed if provider delivers before approval and approval is not given.

Standard DME items must have a minimum one (1) year manufacturer warranty; custom motorized/power wheelchair major components require a two (2) year warranty.

Rental reimbursement counts toward the 10-month rental maximum; after ten (10) consecutive months of rental (including trial) ownership vests to the beneficiary unless otherwise authorized.

Repairs to beneficiary-owned DME reimbursed up to fifty percent (50%) of maximum allowable replacement cost; repairs of rental items are not reimbursed; intentional damage/misuse not reimbursed.

Manual pricing hierarchy for items without assigned DMEPOS fee: (1) MSRP minus 20% (supported by manufacturer/distributor documentation) or (2) provider invoice plus 20% if no MSRP; invoices must be current within one (1) year unless unusual circumstances justify older invoices.

Division may adjust fees based on market research when DMEPOS fees are insufficient or could create access issues.

Reimbursement benchmarks: purchased items reimbursed at 80% of Medicare fee; rental items reimbursed at 10% of Division's allowable fee; used items and repairs reimbursed at 50% of Division's allowable fee.

Prior authorization required for repairs and rental extensions beyond ten (10) months and must include estimated repair cost (including labor) and practitioner statement of continued need.

Maintenance contracts and servicing fees are not covered under the DME program.

Batteries & Chargers

Batteries and single-mode chargers are covered only under specific conditions and require prior authorization.

Sealed batteries and single-mode battery chargers associated with equipment are covered for purchase only when prior authorized by UM/QIO, the Division of Medicaid or designated entity.

Batteries and chargers are included in the maximum reimbursement for associated equipment except power wheelchair batteries (see wheelchair rules).

Replacement batteries are covered when the coverage criteria for replacement are met and when prior authorized.

Maintenance contracts and servicing fees are not covered; batteries/chargers require prior authorization and appropriate documentation per manual pricing rules when applicable.

BiPAP

BiPAP is covered for an initial rental trial and may be recertified when clinical criteria and documentation are met.

Prior authorization by UM/QIO, the Division of Medicaid or designated entity is required.

Initial rental trial up to three (3) months is allowed when one or more of the following apply: beneficiary unable to tolerate CPAP pressures; frequent central apneas not resolved with CPAP; baseline hypoxemia with chronic lung disease or hypoventilation not corrected with CPAP.

All related supplies are integral to the rental/purchase allowance and separate charges for supplies or respiratory services are not covered, except beneficiary-owned supplies may be reimbursed up to maximum expected amounts with justification for excess.

After initial three (3) month trial, BiPAP may be recertified up to seven (7) additional months with a BiPAP Compliance Medicaid Certificate of Medical Necessity completed by the ordering physician; noncompliance or ineffectiveness may require return of equipment and trial rental fees apply toward purchase reimbursement.

Breast Pumps

Breast pumps are covered when medically necessary and prior authorized; documentation requirements apply to prior authorization requests.

Types: Manual pump covered for purchase when used to promote lactation or when breastfeeding not possible; Electric pump covered for rental up to purchase amount or purchase when infant or mother meets specified medical conditions.

Prior authorization must be in the mother's name, include the mother's Medicaid ID number, and include an estimate of the expected duration (weeks or months) of need.

Electric pump purchase allowed when infant conditions (e.g., prematurity with prolonged hospitalization, cleft palate/lip, inability to suck, failure to thrive, low birth weight) or maternal conditions (e.g., breast abscess, mastitis, hospitalization, inability to use manual pump, medications requiring pumping and discarding) justify purchase.

Canes

Canes are covered with prior authorization when clinical criteria for impaired ambulation and potential for ambulation are met.

Prior authorization by UM/QIO, the Division of Medicaid or designated entity is required for rental up to purchase amount or purchase when indicated.

Must have a condition or injury causing impaired ambulation and potential for ambulation (clinical justification required).

Tips, handgrips, adjustment features and other accessory items are inclusive in the rental or purchase and are not reimbursed separately.

Combination Airway Devices

Combination airway oscillation/airway oscillation devices are covered for purchase when specific chronic lung conditions and functional criteria are met.

Prior authorization by UM/QIO, the Division of Medicaid or designated entity is required for purchase.

Indications: Covered diagnoses include chronic lung conditions where secretion mobilization is hindered such as COPD, chronic bronchitis, cystic fibrosis, bronchiectasis, emphysema, atelectasis, or other disease requiring secretion mobilization.

Beneficiary teaching and documentation of ability to properly use and clean the device must be provided.

Item may not be appropriate for children under age six unless the ordering clinician documents the child can use it correctly; individual consideration for children under six years.

Commode Chairs

Commode chairs and raised toilet seats are covered with prior authorization when inability to use regular toilet facilities is documented.

Prior authorization by UM/QIO, the Division of Medicaid or designated entity is required for rental up to purchase amount or purchase when indicated.

Covered when beneficiary is unable to use regular toilet facilities due to physical condition; detachable arms, heavy duty or extra wide commodes covered when documentation of need (weight/measurements) is provided.

Raised toilet seat covered for convalescence from hip surgery or when bedside commode cannot fit over toilet; documentation required.

Compressors

Compressors are covered for rental up to purchase or purchase when required for air-driven equipment and may be separately reimbursed in limited contexts.

Prior authorization by UM/QIO, the Division of Medicaid or designated entity is required for rental up to purchase amount or purchase.

Compressors may be separately reimbursed when used with ventilator, nebulizer, or humidification equipment that is not self-contained or cylinder driven.

CPAP

CPAP is covered as a rental trial with defined clinical thresholds, recertification and supply rules; ownership vests after cumulative rental.

Prior authorization by UM/QIO, the Division of Medicaid or designated entity is required for the three (3) month trial rental period.

Initial rental trial up to three (3) months allowed when respiratory event criteria met: >=15 events/hour, or 5-14 events/hour with documented symptoms (excessive daytime sleepiness, impaired cognition, mood disorders/insomnia, documented hypertension/ischemic heart disease/history of stroke); pediatric polysomnogram criteria specified for children.

After initial three (3) month trial, CPAP may be recertified up to seven (7) additional months with a CPAP Compliance Certificate of Medical Necessity completed by the ordering physician; trial rental fees apply toward purchase reimbursement and if effective/continuous rental reaches ten (10) months, beneficiary owns the CPAP.

Reimbursed supplies (masks, interfaces, cushions, headgear, tubing, filters, humidifier water chamber) are considered part of the rental/purchase allowance; replacement limited to usual maximums unless individual justification provided.

Crutches

Crutches are covered with prior authorization for indicated post-operative, post-injury or long-term use; accessories are included.

Prior authorization by UM/QIO, the Division of Medicaid or designated entity is required.

Type-specific criteria: Underarm crutches covered for post-op/post-injury to reduce weight bearing or progression to ambulation; forearm crutches covered for long-term users and when balance/independence criteria met; customized crutches require prior authorization.

Tips, handgrips, adjustment features and other accessories are inclusive in the rental or purchase of crutches and not reimbursed separately.

EMG Biofeedback

EMG biofeedback devices are rental-only initially and require recertification when continued therapeutic use is indicated.

Prior authorization by UM/QIO, the Division of Medicaid or designated entity is required for rental up to three (3) months.

Recertification required after three (3) month rental when continued therapy (therapeutic exercise, musculoskeletal pain, stress injuries, pre-chronic pain/headache programs) is prescribed and documentation shows desired outcomes and beneficiary capability to use the device.

DME provider must document beneficiary's capability to use and understand the biofeedback device mechanism.

Cochlear Implants / AODs

Coverage for cochlear implants and auditory osseointegrated devices (AODs), and associated batteries/chargers, requires prior authorization and qualified ordering clinicians.

Repairs and external replacement parts are covered when medically necessary and prior authorized by UM/QIO, Division of Medicaid or designee.

Batteries and battery chargers for cochlear implants and implantable/non-implantable AODs are covered when medically necessary and prior authorized; orders must be by qualified specialists (audiologist, otologist, otolaryngologist or other physician with documented training).

Manufacturer must provide a minimum one (1) year warranty for all items.

Gait Trainer

Gait trainers require prior authorization and therapy-based documentation of trainability and potential for ambulation.

Prior authorization by UM/QIO, the Division of Medicaid or designated entity is required; initial rental up to three (3) months then recertification when ordered by appropriate specialist (PM&R, orthopedics, neurology).

PT/OT evaluation (not employed by DME supplier) must document medical necessity, expected duration, functional trainability and participation in therapy; home space and absence of contraindications must be documented.

Beneficiary must have condition causing unsteady gait and difficulty with ambulation and potential to become ambulatory with training.

Rule 1.24 coverage criteria

Rule 1.24 summarizes cochlear/AODs coverage, ordering clinician requirements, batteries and warranty expectations.

Repairs and external replacement parts covered when medically necessary and prior authorized.

Items must be ordered by an audiologist, otologist, otolaryngologist or other physician specialty with documented training in assessment and prescription of cochlear implants/AODs.

Manufacturer must provide a minimum one (1) year warranty for all items.

Prior authorization by UM/QIO, Division of Medicaid or designee is required.

Rule 1.25 coverage criteria

Rule 1.25 defines gait trainer coverage conditions, required evaluations and ordering clinicians.

Gait trainer defined as wide-based frame with casters and possible seat/supports; prior authorization required for rental up to three (3) months then recertification when ordered by PM&R, orthopedics, or neurology.

PT/OT evaluation not employed by DME supplier must document medical necessity, approximate duration, trainability and therapy involvement; adequate home space and no contraindications required.

Beneficiary must have unsteady gait, difficulty with ambulation, and potential to be ambulatory.

Rule 1.26 coverage criteria

Rule 1.26 sets coverage rules for BGMs and CGMs including device types, FDA status and ordering/provider criteria.

BGM covered for rental up to purchase or purchase when prior authorized and ordered by a physician with diagnosis criteria (Type I, Type II with documented out-of-range glucose or requiring meds/special diet, or gestational diabetes) and beneficiary/caregiver can demonstrate testing ability.

Minimally invasive CGM covered for rental up to purchase or purchase when FDA-approved for home use, medically necessary, prior authorized, ordered by physician actively managing diabetes and beneficiary meets Part 225 Rule 4.3 criteria.

CGM devices must be FDA-approved and capable of accurately measuring and transmitting glucose data.

Rule 1.27 coverage criteria

Hip abductor pillow/wedge is purchase-only and requires prior authorization with qualifying diagnoses.

Prior authorization required for purchase only and must be ordered by a physician.

Indications: Covered diagnoses include conditions requiring hip/thigh abduction, subluxing/dislocating hips, unstable hip, post-reduction of dislocated hip, post-hip replacement/arthroplasty/fracture surgery, post-adductor tenotomy/abductor advancement, or wheelchair patients needing hip abduction.

Rule 1.28 coverage criteria

Rule 1.28 details hospital bed categories, clinical criteria, evaluation and warranty/frequency limits.

Hospital beds covered when medically necessary, prior authorized and ordered by a physician for purchase or rental up to purchase amount; definitions include articulating frame, headboard, footboard and mattress with side rails.

Manual/variable/semi-electric criteria: Manual fixed-height covered when positioning needs, head elevation ≥30°, failed pillows/wedges, need to attach equipment, paralysis/immobility, semi-comatose/comatose; variable/semi-electric and bariatric/total electric have additional ordering and evaluation requirements.

Total electric hospital beds require ordering physician with appropriate expertise, documentation of medical necessity and expected hours in bed, on-site OT/PT evaluation certifying exclusive use and installation feasibility, two-year warranty, and no receipt of total electric bed within last five (5) years.

Rule 1.29 coverage criteria

Hydraulic lifts with seat or sling are covered with prior authorization when transfer/positioning criteria and caregiver/training requirements are met.

Prior authorization required for rental up to purchase amount or purchase when ordered by a physician and documentation shows periodic position adjustment needed, bed/chair confinement, and an available trained caregiver.

Seat or sling included in initial purchase/rental price; electric lift mechanisms require physician ordering by specified specialists, on-site OT/PT evaluation, two-year warranty, and no electric lift received within last five (5) years.

Rule 1.30 coverage criteria

Rule 1.30 covers enteral, parenteral, ambulatory and stationary infusion pumps with ordering and clinical-use criteria.

Enteral pumps covered when prior authorized and ordered by a physician if beneficiary is tube-fed and enteral feedings are the sole source of nutrition.

Parenteral pumps covered when prior authorized and ordered by a physician for beneficiaries who cannot absorb nutrients via GI tract.

Ambulatory and stationary pumps covered when prior authorized and ordered by a physician if home parenteral administration is reasonable/medically necessary and pump is necessary to safely administer medication.

Rule 1.31 coverage criteria

Insulin pumps require specialty ordering, documentation of beneficiary suitability and may be rented-to-purchase or purchased when criteria are met.

Prior authorization by UM/QIO, Division of Medicaid or designated entity is required for rental up to purchase amount or purchase when ordered by an endocrinologist or physician experienced with pump therapy.

Indications: Covered when beneficiary has insulin-dependent diabetes with difficult control, fluctuating sugars on ≥3 injections/24 hours, or secondary diabetic complications requiring tighter control.

Prescribing provider must document beneficiary/caregiver motivation, ability to learn and use the pump, commitment to management; comprehensive education must be ensured by provider and supplier.

Rule 1.32 coverage criteria

IV poles are covered when needed for enteral/parenteral fluids or IV medications and not using an ambulatory pump.

Prior authorization required for rental up to purchase amount or purchase when ordered by a physician for beneficiaries receiving enteral or parenteral fluids or IV medications and not using an ambulatory infusion pump.

Rule 1.33 coverage criteria

Nebulizers are covered for rental (acute) or purchase (chronic) when physician-ordered and criteria are met.

Prior authorization required for rental up to purchase amount or purchase when indicated and ordered by a physician.

Use case: Rental only for acute short-term conditions expected to resolve (e.g., pneumonia, acute bronchitis); purchase for chronic/recurring conditions (e.g., asthma, BPD, chronic bronchitis, COPD, cystic fibrosis, respiratory distress syndrome).

Practitioner expected to have considered MDI with/without spacer if age-appropriate before prescribing nebulizer.

Rule 1.34 coverage criteria

NMES is rental-only, prior authorized, and must be ordered by specified specialists with documented clinical criteria.

Prior authorization required; rental only; must be ordered by an orthopedist, neurologist, physiatrist or physician specialized in physical rehabilitation.

Must have documented diagnosis of disuse atrophy with intact nerve supply and meet one of listed clinical situations (casting/splinting, contracture due to scarring, post-hip replacement until orthotic training, need for relaxation/prevention/re-education/increasing circulation/range of motion).

Beneficiary and/or caregiver must demonstrate proper use and care of equipment.

Neuromuscular Electrical Stimulator (NMES)

NMES coverage criteria (condensed): ordering clinician, rental-only, clinical indications and training.

Prior authorization required and rental only.

Ordered by orthopedist, neurologist, or physiatrist.

Documented diagnosis of disuse atrophy with intact nerve supply and one or more qualifying clinical conditions (e.g., casting/splinting, contractures, post-op use, need for muscle re-education).

Oxygen and related equipment

Oxygen and oxygen-related equipment require prior authorization, specific testing and clinical thresholds, and have distinct billing rules for stationary and portable systems.

Prior authorization required before initiation and annually thereafter; attending physician must specify diagnosis, flow rate, frequency, duration, estimated period of need and type of delivery system.

Qualifying blood gas/oximetry testing timing: inpatient within two (2) days of discharge, outpatient within thirty (30) days while stable, or documented contraindication to room air testing.

Group I/II thresholds: Beneficiary must meet Group I or Group II numerical ABG/oximetry thresholds and associated clinical qualifiers (rest, exercise, sleep criteria and signs like cor pulmonale, pulmonary hypertension, erythrocytosis).

Billing rules: stationary oxygen monthly rental fee includes regulators, tubing, cannulas/masks, humidifier, nebulizer, contents, backup equipment, maintenance/repairs/delivery; coding must indicate flow rate via HCPCS codes/modifiers.

Portable oxygen rental is continuous; portable oxygen contents billing limited to one (1) unit per month; cannot bill rental of portable home compressor and portable oxygen contents at same time.

Exclusions: not covered for angina without hypoxemia, dyspnea without cor pulmonale/hypoxia, peripheral vascular desaturation, terminal illnesses not affecting respiratory system, or PRN-only orders.

DME providers must document after each visit: date of service, maintenance/repairs, oxygen output determination, filter changes, and backup system functioning.

Pacemaker monitor

Pacemaker monitors require prior authorization, physician order and beneficiary capability for trans-telephonic monitoring.

Prior authorization by UM/QIO, the Division of Medicaid or designated entity is required for rental up to purchase or purchase when indicated.

Must be ordered by a physician, beneficiary must have an implanted pacemaker, be capable (or caregiver capable) of performing monitoring and have telephone access for transmission.

Pulse oximeter

Pulse oximeters are covered with prior authorization and distinct criteria for non-recording and recording devices.

Prior authorization required; rental up to purchase or purchase when indicated and ordered by a physician.

Non-recording criteria: Non-recording oximeter covered for serious respiratory diagnosis needing short-term oximetry, ventilator dependence with supplemental oxygen, tracheostomy monitoring, unstable saturations on supplemental oxygen, or weaning from oxygen.

Recording oximeter covered when beneficiary meets non-recording criteria and device ordered to document specific events (weaning attempts, feeding times, etc.).

Spacer / Aerosol-Holding Chamber

Spacers/aerosol-holding chambers are purchase-only when inability to coordinate MDI actuation and inhalation is documented along with diagnosis.

Purchase when ordered by a physician and beneficiary unable to coordinate MDI actuation and inhalation, has diagnosis of asthma/chronic bronchitis/emphysema, and possesses a metered dose inhaler.

Device defined as a 4-8 inch cylinder with one-way valve attached to an MDI to slow delivery and reduce oral deposition.

Home suction pump

Home suction pumps (stationary and mobile) are covered with prior authorization when beneficiary cannot clear airway or when portable needs exist for travel.

Prior authorization required for rental up to purchase or purchase when ordered by a physician and beneficiary is unable to clear airway of secretions by coughing due to conditions such as throat cancer/surgery, paralysis of swallowing muscles, tracheostomy, or comatose/semi-comatose state.

Mobile suction units covered when prescribed for secretions requiring suctioning during travel, beneficiary not transported by ambulance, and documentation justifies medical necessity for both stationary and portable units.

Users must be sufficiently trained to use the device safely.

Traction equipment

Traction equipment is rental up to three months with recertification and must be ordered by appropriate specialists with supporting imaging or chronic pain documentation.

Prior authorization required; rental up to three (3) months then recertification required when ordered by an orthopedic physician, neurosurgeon, neurologist or physiatrist.

Beneficiary must have cervical or pelvic orthopedic impairment verified by radiograph or documented chronic pain unrelieved by other treatments; equipment must be appropriate for home use.

TENS

TENS units require prior authorization and have distinct trial/purchase pathways for acute and chronic pain; conductive garments and lead requirements specified.

Prior authorization by UM/QIO, the Division of Medicaid or designated entity is required; rental up to purchase amount or purchase when indicated and ordered by a physician.

Acute vs Chronic: Acute post-op pain: within 30 days post-op, other treatments failed, home use — approval limited to 30 days rental. Chronic intractable pain: ≥3 months duration with failed other modalities — 30-60 day trial required and re-evaluation documentation needed for purchase.

Conductive garments covered only if conventional electrodes are infeasible or contraindicated (large area, inaccessible sites, skin condition, under cast).

If four-lead TENS ordered, practitioner must document why two leads are insufficient.

Transfer board

Transfer boards are covered with prior authorization when specific transfer or caregiver limitations are documented.

Prior authorization required from UM/QIO, Division of Medicaid or designated entity; must be ordered by a physician.

Coverage criteria: Covered when one of: decreased/absent lower extremity function with successful transfer using board; obesity preventing transfer without lifting; required by caregiver for bed mobility; caregiver unable to lift patient.

Trapeze bar/equipment

Trapeze bars/equipment are covered with prior authorization when needed to assist transfers or when integral to a medically necessary hospital bed.

Prior authorization required and physician order required.

Coverage criteria: Covered when beneficiary has truncal or lower extremity weakness needing device to rise to sit, change position, or get in/out of bed; attached trapeze covered when integral to a medically necessary hospital bed; freestanding trapeze covered only with non-hospital bed when beneficiary not renting/owning a hospital bed.

Coverage criteria — Transfer Board (duplicate)

Duplicate transfer board block: prior authorization and physician order plus one-of clinical criteria.

Prior authorization required from UM/QIO, Division of Medicaid or designated entity.

Ordered by a physician.

One of: Decreased/absent lower extremity function; obesity preventing transfer without lifting; required by caregiver for bed mobility; caregiver unable to lift patient.

Coverage criteria — Trapeze Bar/Equipment (duplicate)

Duplicate trapeze block: prior authorization, physician order and attached vs freestanding distinctions.

Prior authorization required and physician order required.

Covered when beneficiary has truncal or lower extremity weakness to rise/sit/change position/get in/out of bed.

Attached trapeze covered when integral to medically necessary hospital bed; freestanding trapeze covered only with non-hospital bed and when beneficiary not renting/owning a hospital bed.

Coverage criteria — Ventilator

Ventilators are rental-only with strict clinical ordering criteria and rental allowance that includes full service components.

Prior authorization required; ventilators are covered for rental only and must be ordered by a physician.

Clinical criteria: Covered when beneficiary cannot maintain spontaneous respiration; cannot maintain safe arterial CO2 or oxygen with spontaneous breathing; or requires mechanically assisted ventilation appropriate for home use without continuous professional supervision.

Rental allowance includes equipment, delivery, freight/postage, set-up, supplies necessary for operation, patient/caregiver education, maintenance and repairs, labor including respiratory therapy visits, and servicing charges.

Coverage criteria — Walker

Walkers require prior authorization and physician order with device-type-specific functional criteria.

Prior authorization and physician order required.

Rigid/folding walker: Beneficiary has impaired ambulation with potential to ambulate and needs greater stability than canes/crutches.

Pickup/wheeled walkers: Specific balance, transport and rolling-balance criteria apply; must be able to maintain balance and have means to transport when required.

Specific provisions for heavy duty, attachments, seating and hand brakes when medically necessary.

Coverage criteria — Custom Wedge Seat Insert

Custom wedge seat inserts are purchase-only and require prior authorization, physician ordering and independent PT/OT assessment.

Prior authorization required for purchase only and must be ordered by specified physicians (pediatrician, orthopedist, neurosurgeon, neurologist, physiatrist).

Beneficiary must have stable seating or mobility device to allow use, and need must be to decrease posterior pelvic tilt or assist with proper positioning.

Assessment/evaluation by a PT or OT not employed by DME supplier/manufacturer is required; not covered if existing custom seating provides similar benefits.

Coverage criteria — Wheelchairs and Accessories

Wheelchairs and accessories require physician order, prior authorization, thorough evaluations and have frequency, warranty, and provider certification requirements.

Physician order and prior authorization required; provider must fully assess beneficiary needs and perform measurements; beneficiary, caregiver and vendor recommended to be present for assessment/delivery.

Standard vs Custom vs Motorized: Standard wheelchairs covered when beneficiary would be otherwise bed/chair confined; custom and motorized/power wheelchairs have detailed medical necessity, face-to-face exam, PT/OT evaluations and ordering specialist requirements.

Frequency limit: one (1) standard or custom motorized/power wheelchair per beneficiary every five (5) years based on medical necessity; reimbursement includes labor, covered additions/accessories and support services; payment only after subsequent PT/OT verification.

Custom motorized/power wheelchairs require two (2) year warranty on major components, lifetime frame warranty for powered mobility base, and specified warranty terms for electronics and cushions; provider responsible for repairs if no warranty.

Provider must have at least one ATP-certified RESNA employee registered with NRRTS involved in selection; certifications must be current or prior authorization denied.

Major repairs/replacements require prior authorization with estimated cost including labor and practitioner documentation; reimbursement rules limit rental while repaired to up to one month.

Motorized/power wheelchairs not covered for leisure, caregiver convenience, ambulatory beneficiaries or non-compliant beneficiaries; home/environmental adaptations not covered.

Wheelchair Accessories Coverage Criteria

Wheelchair accessories are covered when physician-ordered, medically necessary, prior authorized and when beneficiary already meets wheelchair coverage criteria; some accessories are included in base rate.

Accessory examples: Detachable or swing-away armrests, mobile arm supports, fully reclining backs (when quadriplegia or fixed hip angle or other listed reasons), reinforced upholstery for morbid obesity or movement disorders, calf pads, cylinder tank carriers, heel loops/ankle straps, headrest extensions, IV hangers, leg straps, low pressure/positioning pads, one-arm drive attachments and other accessories when criteria met.

Certain items are included in the wheelchair base rate and are not reimbursed separately (arms, footrests/footplates, elevating leg rests, standard safety belts, manual/automatic wheel locks when criteria apply); crutch/cane holders on back post are not covered.

Any other accessory deemed medically necessary will be considered on an individual basis with appropriate documentation.

Humidifier Coverage Criteria

Humidifiers and HMEs are covered when chronic respiratory indications or device-specific needs exist; prior authorization and documentation of caregiver/patient ability required.

Prior authorization by UM/QIO, the Division of Medicaid or designated entity required for rental up to purchase or purchase; ordered by a physician and medically necessary.

Room humidifiers/HMEs: Room humidifiers/vaporizers covered for chronic respiratory diagnoses (chronic bronchitis, asthmatic bronchitis, chronic asthma, BPD, chronic airway obstruction) with documentation that patient/caregiver can use and care for equipment; HMEs covered when tracheostomy present and supplemental direct humidification required.

High-flow/water reservoir humidifiers covered for tracheostomy, CPAP/BiPAP (when device criteria met) and ventilators (when ventilator criteria met); humidifiers included in rental/purchase price when used with oxygen or IPPB treatments.

Not covered for acute upper respiratory infections or isolated coughs/colds unrelated to another diagnosis.

Pressure Reducing Support Surface Coverage Criteria

Pressure reducing support surfaces (powered and non-powered) require prior authorization, physician order, and a documented care plan.

Prior authorization by UM/QIO, the Division of Medicaid or designated entity required for rental up to purchase or purchase and must be ordered by a physician when medically necessary.

Care plan must document education on ulcer prevention/management, regular assessment, turning/positioning, wound care for stage II-IV, moisture/incontinence management and nutritional assessment/intervention.

Indications: Non-powered pressure pads covered for immobility, limited mobility, any stage pressure ulcer on trunk/pelvis, or bedbound with impaired nutrition/incontinence/altered sensation/compromised circulation. Powered overlays/mattresses covered for multiple stage II ulcers, ulcers not improved after one month of comprehensive program, large/multiple stage III/IV ulcers on trunk/pelvis, or recent myocutaneous flap/skin graft within 60 days.

Foam overlays/mattresses without waterproof cover are not considered durable and are not covered.

Covered Medical Supplies and Provider Obligations

Medical supplies require physician prescription, a completed Medical Supply CMN, 30-day dispensing limits, delivery documentation, and specific coverage rules for supply categories.

All medical supplies must be prescribed by a licensed physician; Medical Supply CMN must be completed by the DME provider and signed by the ordering physician within 30 days of delivery and retained in provider records; prescriptions/CMNs must be renewed every 12 months.

Providers must only dispense supplies in quantities to meet the beneficiary's needs for thirty (30) days; beneficiary must request supplies monthly; supplies may be delivered no more than ten (10) calendar days prior to expected end of current supply.

Delivery documentation must include beneficiary name, delivery address, detailed item description and HCPCS code, quantity, date of delivery (date beneficiary received item), and beneficiary signature (with emergency exceptions).

Examples and rules: Covered supplies include alcohol preps, apnea monitor supplies, diabetic supplies (BGM test strips, lancets, insulin syringes, control solutions), CGM supplies as a bundled allowance (disposable sensors and transmitter) with DME receiver rules, dressing supplies, EMG supplies, enteral feeding supplies, IV/infusion supplies and other listed categories when criteria met.

CGM supplies covered as bundled sensors and transmitter; separately billed supplies will not be covered; DME receiver covered when used alone or with non-DME devices; supply allowance not covered if DME receiver never used.

Coverage criteria for specific supply categories

Coverage criteria for specific supply categories list covered items and any special conditions for supply provision.

Diabetic supplies: Includes BGM test strips, lancets, insulin syringes, control solutions, replacement batteries, spring lancet devices, autoclix lancets, urine test strips; CGM supply allowance covers bundled sensors and transmitter; DME receiver rules apply.

Enteral feeding supplies: Feeding bags, syringes, sterile water, sterile solutions, gloves and related items covered when enteral feeding criteria are met.

IV and infusion supplies: Cassettes, replacement batteries, central line supplies, administration sets, tubing, clamps, flush kits, sterile saline and related items covered when pump/IV criteria met.

Elbow and heel protectors: Covered when beneficiary is bed/chair confined with history or current decubitus ulcers or shows redness/discomfort at bony prominences.

Insulin pen needles via medical supply program: Covered only if beneficiary cannot read syringe markings or cannot manipulate vial/syringe due to hand condition; otherwise provided through pharmacy program.

Tracheostomy supplies: Extensive list covered (masks, inner cannula, suction catheters, HME, sterile water, saline, ties, cleaning brush) when documentation of specific respiratory condition provided.

Urinary catheters: Covered when acute/chronic criteria met (intermittent catheterization needs, short-term indwelling use, incontinence causing pressure sores, need for accurate I&O short-term, urinary retention not relieved by meds); supplies include insertion/irrigation trays, catheters, drainage bags, gloves and require beneficiary/caregiver capability and instruction.

Incontinence garments and supplies coverage and administrative requirements

Incontinence garments and supplies are covered when medically necessary with CMN and ordering/recertification rules and defined quantity limits.

Disposable incontinence garments and supplies covered when medically necessary; physician order and CMN required with detailed item descriptions and HCPCS codes; CMN must be renewed every six (6) months (or every twelve (12) months for chronic documented cases).

Beneficiaries aged three (3) and above may receive up to six (6) units of incontinence garments per day without prior authorization; prior authorization required for quantities in excess of the limit.

Monthly supply limits: up to 400 personal sanitary wipes/month, up to 200 pairs non-sterile gloves/month, up to 2 units non-medicated skin protectant/month; prior authorization required for excess quantities.

DME provider must document proof of delivery including beneficiary name, delivery date (date received), delivery address, detailed description of items, expected duration of delivered quantity, and maintain CMN in beneficiary record.

Non-covered supplies

Certain supplies are explicitly non-covered under the DME medical supplies program.

Oral hygiene supplies (toothbrushes, dental floss, toothpaste, toothettes, lemon glycerin swabs and other non-specific oral hygiene items) are non-covered.

EPSDT

EPSDT-eligible beneficiaries receive medically necessary services without regard to certain service limitations subject to prior authorization.

The Division pays for all medically necessary services for EPSDT-eligible beneficiaries in accordance with Part 223 of Title 23 without regard to service limitations and with prior authorization as required.

Diabetic supply rebate program and pharmacy billing

Diabetic supply rebate program and pharmacy billing rules affect how diabetic supplies are billed and which items are subject to rebate program provisions.

The Division may operate a diabetic supply rebate program; diabetic supplies on the Preferred Diabetic Supply List are included and providers are prohibited from collecting manufacturer rebates on those items.

Diabetic supplies included on the Preferred Diabetic Supply List provided by a pharmacy may be billed on a pharmacy claim, but diabetic supplies billed through pharmacies must comply with medical supply coverage requirements as applicable.

CGM supplies are treated as a bundled supply allowance (disposable sensors and transmitter); separately billed supplies will not be covered and DME receiver rules apply.

Coding, billing, and reimbursement details

HCPCS identification on delivery/PODmixed

HCPCS

Documentation of HCPCS codes required on proof of delivery and delivery records

CPAP clinical thresholdsmixed

CPAP coverage criteria tied to respiratory events: 15 or more respiratory events per hour, or 5–14 events/hour with qualifying symptoms (e.g., excessive daytime sleepiness, impaired cognition).

No billing codes specifiedmixed

No codes listed

Oxygen HCPCS coding guidanceHCPCS

HCPCS

Providers must include appropriate HCPCS codes indicating prescribed flow rate and modifiers (e.g., codes indicating 1–4 LPM, <1 LPM, >4 LPM) when billing stationary or portable oxygen contents and to indicate flow rates/modifiers for monthly rental vs contents billing.

Reimbursement and billingmixed

HCPCS

When available, providers must bill using appropriate HCPCS procedure/service codes; unlisted/bundled HCPCS codes may be used for custom or miscellaneous DME where no specific code exists.

Procedure coding and delivery documentationmixed

HCPCS

Providers must use appropriate procedure/HCPCS code for billed items and include HCPCS codes on delivery documentation (POD) with item description, quantity, date of delivery and beneficiary signature as proof of delivery.

Incontinence garment item coding on CMNHCPCSCovered

HCPCS

The CMN must include a detailed description of each incontinence garment item including the type, size and corresponding HCPCS code for each item delivered.

Reimbursement rates — purchased/rental/used items percent benchmarks

Purchased items reimbursementPurchased items reimbursed at 80% of the Medicare fee.

Rental items reimbursementRental items reimbursed at 10% of the Division of Medicaid's allowable fee.

Used items / repairs reimbursementUsed DME and/or repairs reimbursed at 50% of the Division of Medicaid's allowable fee.

Manual pricingItems without an assigned allowable fee are manually priced by the Division of Medicaid.

Maximum recertification months for apnea monitors — timing limit

Initial certification periodApnea monitors covered for an initial three (3) month certification (trial).

Maximum recertificationAfter the initial 3-month certification, apnea monitors may be recertified up to seven (7) additional months with a new prescription or letter of medical necessity.

Recertification documentationRecertification requires a new prescription or letter of medical necessity from the ordering clinician.

CPAP respiratory events — clinical thresholds for coverage

High event-rate threshold (adults)Coverage when beneficiary experiences fifteen (15) or more respiratory events per hour.

Moderate event-rate with symptoms (adults)Coverage when 5–14 respiratory events/hour occur with documented symptoms such as excessive daytime sleepiness or impaired cognition.

Pediatric threshold (prepubescent)For prepubescent children, coverage when respiratory events are greater than or equal to one (1) event per hour per polysomnogram criteria.

Initial rental/trial period — common 3-month trial guidance

Common trial period lengthInitial rental/trial period for CPAP and BiPAP (and several other devices) is three (3) months.

Trial counts toward rental-to-purchaseRental/trial fees paid during the initial three-month trial apply toward the maximum reimbursement for purchase.

Prior authorization for trialInitial three-month rental trial requires prior authorization by UM/QIO, the Division of Medicaid, or designated entity.

Device replacement frequency limits referenced — 5-year replacement limits for some devices

Five-year replacement interval (beds/lifts/wheelchairs)Certain major devices (e.g., total electric hospital bed, electric lift mechanism, and standard/custom motorized/power wheelchairs) are limited so beneficiary must not have received the same device within the last five (5) years.

Wear-and-tear replacementReplacement for wear and tear is reimbursed every five (5) years unless extenuating circumstances documented.

Warranty requirementsTotal electric hospital beds and electric lifts require a full two (2)-year warranty; major components of custom power wheelchairs have a two-year warranty.

Portable oxygen contents billing limit — 1 unit/month restriction

Portable oxygen contents billing capProvider is not allowed to bill portable oxygen contents exceeding one (1) unit per month; a unit is defined as the quantity of oxygen the beneficiary uses per month.

Coding requirementBilling for oxygen requires appropriate HCPCS codes and modifiers indicating prescribed flow rate and whether flow is <1 LPM, >4 LPM, etc.

Monthly rental inclusionMonthly rental for portable oxygen systems includes regulators, tubing, cannulas/masks, humidifier, portable container and supply reservoir; contents billed separately limited to one unit/month.

Wheelchair frequency limit — one per five years

Wheelchair frequency limitStandard and custom motorized/power wheelchairs are limited to one (1) per beneficiary every five (5) years based on medical necessity.

One wheelchair reimbursed at a timeReimbursement is made only for one (1) wheelchair at a time and includes labor and covered additions/accessories.

Documentation and evaluationsProvision requires physician order, prior authorization, and PT/OT evaluations with subsequent evaluation completed before reimbursement is made.

Supply dispensing interval — 30-day dispensing rule

Dispensing intervalProviders must only dispense medical supplies in quantities to meet the beneficiary's needs for thirty (30) days.

Monthly beneficiary requestThe beneficiary must request the supplies each month; supplies cannot be shipped automatically.

Delivery documentationProviders must document delivery with beneficiary name, address, detailed item description and HCPCS, quantity, date of delivery, and beneficiary signature (exceptions during emergencies).

Early delivery allowance — no earlier than 10 days before depletion

Early delivery allowanceSupplies provided on a reoccurring basis may be delivered no more than ten (10) calendar days prior to the expected end of the current supply.

No automatic shipmentsSupplies cannot be shipped on an automatic basis; beneficiary must request monthly.

Documentation requirementProviders must retain delivery documentation including HCPCS codes and beneficiary signature; alternate confirmation allowed during emergencies.

Incontinence garment daily limit — 6 units/day without prior authorization

Daily incontinence garment limitUp to six (6) units of incontinence garments per day for beneficiaries aged three (3) and above without prior authorization; one unit = one diaper, pull-on, or underpad.

Prior authorization for excessPrior authorization required for quantities in excess of six (6) units per day for beneficiaries age three and above.

CMN and renewalPhysician must certify medical necessity and DME provider must maintain CMN; CMN renewal frequency specified elsewhere (6 or 12 months depending on chronicity).

Personal sanitary wipes limit — 400/month

Personal sanitary wipes monthly limitUp to four hundred (400) personal sanitary wipes per month without prior authorization.

Prior authorization for excessPrior authorization required for quantities in excess of 400 wipes per month.

Association with incontinence suppliesWipes are listed among covered disposable incontinence supplies and subject to medical necessity documentation.

Non-sterile gloves limit — 200 pairs/month

Non-sterile gloves monthly limitUp to two hundred (200) pairs of non-sterile gloves per month without prior authorization.

Prior authorization for excessPrior authorization required for quantities in excess of 200 pairs per month.

Covered as incontinence supplyNon-sterile gloves are included in the list of covered disposable incontinence supplies when medically necessary.

Non-medicated skin protectant — 2 units/month

Non-medicated skin protectant monthly limitUp to two (2) units of non-medicated skin protectant per month without prior authorization.

Prior authorization for excessPrior authorization required for quantities in excess of two (2) units per month.

Included in incontinence suppliesNon-medicated skin protectant is listed among covered disposable incontinence supplies when medically necessary.

Prior authorization, documentation, and supplier obligations

Prior Authorization

Submit PA before or within 30 days of delivery

Prior authorization must be submitted prior to or within thirty (30) days of delivery; prior authorization is a medical necessity review conducted by the UM/QIO, the Division of Medicaid, or a designated entity. If a provider delivers the item before submitting a prior authorization request and approval is not given, the beneficiary may not be billed.

Prior Authorization

Include cost estimate and physician statement for repair PA

Repair prior authorization must include an estimated cost of necessary repairs, including labor, and a statement from the physician that there is a continued need for the DME or medical appliance; the UM/QIO, Division of Medicaid or designated entity performs the review.

Include estimated repair cost (including labor)
Include physician statement of continued need

Documentation Required

Provide product/manufacturer details for manual pricing requests

When requesting manual pricing, the provider must identify the product name, product number, and the manufacturer or distributor and provide the required documentation to support pricing under the manual pricing hierarchy.

Provide product name and product number
Provide manufacturer or distributor name
Submit required documentation (MSRP documentation or invoice per hierarchy)

Prior Authorization

PA required for apnea monitors and augmentative communication devices

Apnea monitors and augmentative communication devices (ACDs) require prior authorization by the UM/QIO, the Division of Medicaid, or a designated entity; apnea monitors are covered for an initial three-month rental trial and ACDs are prior authorized for rental up to purchase amount or purchase as indicated.

Apnea monitors: prior authorization required; initial 3-month rental trial applies toward purchase reimbursement
ACDs: prior authorization required for rental up to purchase amount or purchase when criteria met

Billing Rule

Maintenance contracts excluded; battery/charger PA rules

Maintenance contracts and servicing fees are not covered under the DME program. Batteries and battery chargers require prior authorization and are covered for purchase only when associated with equipment and meeting the coverage criteria.

Do not bill Medicaid for maintenance contracts or servicing fees
Batteries/battery chargers: prior authorization required; covered for purchase when associated with equipment per rule

Prior Authorization

PA required for batteries and chargers associated with equipment

Sealed batteries and single-mode battery chargers are covered for purchase only when prior authorized by UM/QIO, the Division of Medicaid, or designated entity and when associated with the purchase of equipment (except power wheelchair batteries); replacement batteries require meeting coverage criteria.

PA required for batteries and chargers
Covered for purchase only when associated with equipment (power wheelchair batteries excluded)
Replacement batteries covered if coverage criteria met

Prior Authorization

BiPAP requires PA and a 3-month rental trial

BiPAP coverage requires prior authorization by UM/QIO, the Division of Medicaid, or a designated entity for an initial three-month rental trial; after the initial three-month trial the BiPAP may be recertified up to seven additional months with a completed BiPAP Compliance Medicaid Certificate of Medical Necessity by the ordering physician.

Initial rental trial: 3 months with PA
Recertification: up to 7 additional months with BiPAP Compliance CMN completed by ordering physician

Documentation Required

Breast pump PA and required documentation

Breast pumps require prior authorization by UM/QIO, the Division of Medicaid, or a designated entity; all PA requests must be in the mother's name, include the mother's Medicaid ID number, and include an estimate of how many weeks or months the electric pump will be required.

PA requests must be in mother beneficiary's name
Include mother's Medicaid ID number
Include estimated duration (weeks or months) of need

Prior Authorization

Canes require PA; accessories included

Canes require prior authorization by UM/QIO, the Division of Medicaid, or a designated entity for rental up to purchase amount or purchase when indicated; accessories (tips, handgrips, adjustment features) are included in the rental or purchase.

PA required for canes (rental up to purchase or purchase when indicated)
Do not bill separately for tips, handgrips, adjustment features

Prior Authorization

PA required for combination airway oscillation devices (purchase)

Combination airway oscillation devices require prior authorization by UM/QIO, the Division of Medicaid, or a designated entity for purchase when the beneficiary has an indicated chronic lung condition.

PA required for purchase
Document beneficiary teaching and ability to use/clean device

Prior Authorization

PA required for commode chairs and raised toilet seats

Commode chairs and raised toilet seats require prior authorization by UM/QIO, the Division of Medicaid, or a designated entity for rental up to purchase amount or purchase when indicated; document when heavy duty/extra wide models or detachable arms are required.

PA required for rental up to purchase amount or purchase
Maintain documentation for weight/measurements when heavy duty/extra wide models are requested

Prior Authorization

Compressors require PA for rental or purchase

Compressors require prior authorization by UM/QIO, the Division of Medicaid, or a designated entity for rental up to purchase amount or purchase; separate reimbursement allowed when used with non-self-contained or non-cylinder driven ventilator/nebulizer/humidification equipment.

PA required for rental up to purchase or purchase
May be reimbursed separately when used with certain non-self-contained equipment

Prior Authorization

CPAP requires PA and specific clinical event thresholds

CPAP rental for the three-month trial period requires prior authorization by UM/QIO, the Division of Medicaid, or designated entity and initiation must meet clinical criteria (e.g., ≥15 respiratory events/hour or 5–14 events/hour with qualifying symptoms).

PA required for initial 3-month CPAP trial
Adhere to event-rate and symptom-based clinical thresholds for initiation

Prior Authorization

PA required for crutches (including customized crutches)

Crutches require prior authorization by the UM/QIO, the Division of Medicaid, or a designated entity; customized crutches also require prior authorization.

PA required for crutches
PA required for customized crutches

Prior Authorization

EMG biofeedback PA and recertification requirements

EMG biofeedback devices require prior authorization by UM/QIO, the Division of Medicaid, or a designated entity for rental up to three months, with recertification required when continued therapy is prescribed and documentation that the beneficiary can use the device.

Initial rental up to 3 months with PA
Recertify when continued therapeutic use is prescribed
Document beneficiary capability to use device

Prior Authorization

PA required for cochlear implants/AODs; ordering clinician requirements

Cochlear implants and auditory osseointegrated devices, including batteries and chargers, require prior authorization by UM/QIO, the Division of Medicaid, or designee and must be ordered by qualified specialists; manufacturer must provide a minimum one-year warranty.

PA required for cochlear implants/AODs and associated batteries/chargers
Orders must be by audiologist, otologist, otolaryngologist or similarly trained physician
Manufacturer must provide minimum one-year warranty

Prior Authorization

Gait trainer PA and therapy documentation requirements

Gait trainers require prior authorization by UM/QIO, the Division of Medicaid, or designated entity for rental up to three months; recertification and a PT/OT evaluation (not employed by the DME supplier) documenting medical necessity and expected duration are required when continued use is requested.

PA required for initial rental up to 3 months
Submit PT/OT evaluation report with PA request documenting medical necessity and approximate length of need
Order must be by physician specializing in PM&R, orthopedics, or neurology

Prior Authorization

General PA requirement for many DME items

Prior authorization by the UM/QIO, the Division of Medicaid, or designee is required for coverage of cochlear implants, implantable and non-implantable AODs, batteries and chargers, repairs/replacement parts, and similar DME items across this chapter.

Documentation Required

Ensure appropriate ordering clinician and include item-specific documentation with PA

Most DME items require a physician or specified qualified clinician order and prior authorization by UM/QIO, the Division of Medicaid, or designated entity; PA requests should include the ordering details and clinical documentation specified for each item.

Ensure order is from required specialty/qualified clinician where specified
Include item-specific clinical documentation with PA request

Prior Authorization

NMES PA and specialty ordering requirements

NMES devices are prior authorized for rental only and must be ordered by an orthopedist, neurologist, physiatrist or physician specialized in physical rehabilitation; the request must document a diagnosis of disuse atrophy with intact nerve supply and beneficiary/caregiver ability to demonstrate proper use.

PA required; rental only
Ordering clinician must be orthopedist, neurologist, or physiatrist
Document diagnosis of disuse atrophy and intact nerve supply
Beneficiary/caregiver must demonstrate proper use

Prior Authorization

Oxygen requires initial PA and annual recertification with detailed physician order

Oxygen and oxygen-related equipment require prior authorization by the Division of Medicaid or designee prior to initiation and annually thereafter; the attending physician must specify diagnosis, flow rate, frequency, duration, estimated period of need, and type of delivery system.

PA required before initiation and annually
Physician order must specify diagnosis, flow rate, frequency/duration, estimated period of need, and delivery system

Documentation Required

Document oxygen maintenance, output, filter changes and backup functioning after each visit

After each visit, the DME provider must document date of service, maintenance/repairs and operation/safety of oxygen equipment, determination of oxygen output, filter changes, and proper functioning of the backup system in the beneficiary's record.

Document date of service
Document maintenance/repairs and operation/safety
Document oxygen output determination
Document filter changes and backup system functioning

Prior Authorization

Pacemaker monitor PA and ordering requirements

Pacemaker monitors require prior authorization by UM/QIO, the Division of Medicaid, or designated entity for rental up to purchase amount or purchase when indicated, and must be ordered by a physician with beneficiary/caregiver capability to perform monitoring and telephone access.

PA required for rental up to purchase or purchase when indicated
Ordered by physician; beneficiary/caregiver must be capable of monitoring and have phone access

Prior Authorization

Pulse oximeter PA and clinical criteria documentation

Pulse oximeters require prior authorization by UM/QIO, the Division of Medicaid, or designee; non-recording and recording devices have distinct clinical criteria that must be met and documented in the PA request.

PA required for non-recording and recording pulse oximeters
Document patient meets non-recording criteria or, for recording devices, document monitoring purpose and criteria

Prior Authorization

PA required for spacers, suction pumps, traction, TENS, transfer boards, trapeze

Other DME items such as spacers, suction pumps, traction equipment, TENS, transfer boards, and trapeze bars require prior authorization by UM/QIO, the Division of Medicaid, or designee; coverage typically allows rental up to purchase amount or purchase when indicated and device-specific ordering clinician and clinical criteria apply.

PA required for these items
Follow device-specific ordering clinician and clinical criteria
Rental up to purchase amount or purchase when indicated

Prior Authorization

Transfer boards require PA and physician order with qualifying criteria

Transfer boards are covered only when prior authorized by UM/QIO, the Division of Medicaid, or designated entity; the order must be by a physician and at least one qualifying criterion (e.g., decreased lower extremity function, obesity preventing transfer, caregiver need) must be met and documented.

PA and physician order required
Document which qualifying criterion is met (decreased/absent lower extremity function, obesity preventing transfer, caregiver requirement, caregiver unable to lift)

Prior Authorization

Trapeze bar/equipment PA and ordering requirements

Trapeze bars/equipment require prior authorization by UM/QIO, the Division of Medicaid, or designated entity for rental up to purchase amount or purchase when indicated and must be ordered by a physician with the applicable clinical justification documented.

PA and physician order required
Document clinical need (truncal or lower extremity weakness requiring device to rise to sit/change position/get in/out of bed)
Attached trapeze: document integral use with a hospital bed when both are medically necessary

Prior Authorization

Ventilators require PA, are rental-only, and need physician order

Ventilators are covered only for rental when prior authorized by UM/QIO, the Division of Medicaid, or designated entity and must be ordered by a physician meeting specified clinical criteria (inability to maintain spontaneous respiration or safe arterial gas levels, or need for mechanically assisted ventilation appropriate for home use).

PA required; rental only
Ordered by a physician with documented qualifying clinical criteria

Prior Authorization

Wheelchairs require PA, physician order and PT/OT evaluations

Wheelchairs and wheelchair accessories require prior authorization and a physician order; assessments and evaluations by PT/OT (not employed by the DME supplier) and thorough documentation are required for motorized/power and custom wheelchairs.

PA and physician order required for wheelchairs and accessories
Perform beneficiary assessment and measurements; involve PT/OT evaluations where specified
For motorized/power/custom chairs, include detailed documentation and specialist involvement

Prior Authorization

PA required for humidifiers and pressure reducing support surfaces

Humidifiers and pressure reducing support surfaces require prior authorization by UM/QIO, the Division of Medicaid, or designated entity for rental up to purchase amount or purchase, and coverage requires a physician order and documentation such as a care plan for pressure surfaces.

PA and physician order required
For pressure surfaces, maintain a care plan documenting ulcer prevention/management and related components

Documentation Required

Complete CMN and renew prescription/CMN every 12 months

Medical supplies must be prescribed and a Medical Supply Certificate of Medical Necessity (CMN) completed and signed by the ordering physician every twelve (12) months to remain current.

CMN/prescription must be signed by ordering physician and renewed every 12 months
No coverage if there is no current prescription/CMN

Billing Rule

Dispense supplies for 30 days; beneficiary must request monthly

Providers must only dispense medical supplies in quantities to meet a beneficiary's needs for thirty (30) days; the beneficiary must request supplies each month, supplies cannot be shipped automatically, and deliveries may be made no more than ten (10) calendar days before the expected end of the current supply.

Dispense only 30 days' supply at a time
Beneficiary must request supplies monthly; no automatic shipments
Early delivery allowed up to 10 calendar days before expected end of current supply

Prior Authorization

PA and CMN requirements for incontinence supplies over limits

Prior authorization is required for incontinence garment quantities exceeding six (6) units per day for beneficiaries age three (3) and above; DME providers must maintain a current CMN signed by the ordering physician (including diagnosis, anticipated frequency/duration, requested quantity, item description and HCPCS) and renew the CMN every six months (or every 12 months for chronic documented cases).

PA required for quantities exceeding 6 units/day (age 3+)
DME provider must keep current CMN with required elements
CMN renewal: every 6 months (12 months for chronic cases)

Billing Rule

CGM supplies must be billed as bundled allowance (no separate supply billing)

CGM supplies are covered only as a bundled supply allowance including disposable sensors and transmitter; supplies billed separately will not be covered.

Bill CGM supplies as the bundled allowance only (sensors + transmitter)
Separately billed supplies will not be covered

Definitions used in this policy

Durable Medical Equipment (DME) / Medical Appliance definition

DME / Medical ApplianceAn item that (1) withstands repeated use; (2) is reusable/removable; (3) is primarily used for a medical purpose; (4) is generally not useful absent a disability/illness/injury; and (5) is appropriate for use outside inpatient settings.

CMN linkageMedical Supply CMN must be completed and signed by ordering physician within 30 days of delivery and retained in provider records.

Prior authorization definitionPrior authorization is authorization for a service or item based on medical necessity review by UM/QIO, the Division of Medicaid, or designated entity.

Prior authorization definition

DefinitionPrior authorization is authorization for a service or item based on medical necessity review by the Utilization Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid, or a designated entity.

Timing requirementMust be submitted prior to or within thirty (30) days of delivery for DME and medical appliances.

Effect of no approvalBeneficiary cannot be billed if provider delivers prior to authorization request and approval is not given.

Allowed non-physician practitioner definition

Included practitionersAllowed non-physician practitioners include nurse practitioners, clinical nurse specialists, certified nurse midwives (in collaborative relationship with an enrolled physician), and physician assistants under supervising physician as required by state licensure.

Scope requirementServices must be within the practitioner's scope of practice and collaborative agreement procedures to satisfy order requirements.

Enrollment noteOrders must be from practitioners enrolled as Mississippi Medicaid providers.

Home definition

Home definitionHome is any setting where normal life activities take place other than a hospital, nursing facility, ICF/IID, or any setting where payment could be made by Medicaid for inpatient services including room and board.

RelevanceMany DME coverage rules specify items appropriate for home use and require documentation that device is appropriate for home setting.

Exclusion implicationItems intended primarily for inpatient settings are not considered DME for this program.

Trial period definition

Trial period definitionTrial period is the time required to assess effectiveness of an item and beneficiary compliance; commonly used initial trial is three (3) months for many respiratory and therapeutic devices.

Counts toward rental capTrial periods apply toward the ten (10) month rental maximum and fees paid during trial apply toward purchase reimbursement.

Recertification requirementAfter trial, many devices require recertification with physician documentation or Compliance Certificate of Medical Necessity to continue rental.

Apnea monitor definition

DefinitionApnea monitor: device used to monitor respiratory movements including apnea alarm mattresses or alarm-sensitive devices measuring thoracic/abdominal movement and heart rate.

Coverage noteApnea monitors require prior authorization and are covered for an initial 3-month rental trial with possible recertification.

Return ruleApnea monitors must be returned to provider if rental period is less than ten (10) months.

Augmentative Communication Device (ACD) definition

DefinitionAugmentative Communication Device (ACD): any system allowing beneficiaries with severe expressive communication disorders or speech-language impairments to express messages and overcome communication impairment.

Coverage linkageACDs require prior authorization and specified evaluations (SLP) and ordered by trained physicians; trial periods 30–90 days referenced in related guidance.

Documentation requirementSLP evaluation and device specification must be submitted with prior authorization request.

Battery / Battery charger definition group

Group definitionBattery: device generating electric current by chemical action. Battery charger: device that adds electrical energy to a battery.

Coverage conditionSealed batteries and single-mode chargers covered for purchase when prior authorized and associated with equipment; batteries included in maximum equipment reimbursement except power wheelchair batteries.

Replacement ruleReplacement batteries covered if coverage criteria met and prior authorized.

Battery definition

DefinitionBattery: device for generating electric current by chemical action.

Coverage noteSealed batteries covered for purchase when associated with equipment and prior authorized; exclusions for power wheelchair batteries referenced elsewhere.

DocumentationPrior authorization required and documentation of association with equipment must be provided.

Battery charger definition

DefinitionBattery charger: device that adds electrical energy to a battery.

Coverage noteSingle-mode battery chargers covered for purchase when prior authorized and associated with equipment; prior authorization by UM/QIO/DOM required.

ExclusionsMaintenance contracts and servicing fees are not covered.

BiPAP definition

DefinitionBiPAP is a non-continuous, bilevel airway management device that cycles between inspiratory and expiratory pressure levels in response to the patient's respiratory effort.

Coverage noteBiPAP covered for rental initial three (3) month trial when specific intolerance or clinical criteria met; related supplies integral to rental/purchase.

RecertificationAfter initial 3-month trial, BiPAP may be recertified up to seven (7) additional months with a Compliance Certificate of Medical Necessity.

Breast pump definition

DefinitionBreast pump: device used to extract breast milk from a lactating mother; includes manual and electric types with differing coverage conditions.

Coverage specificsManual pumps covered for purchase when used to promote lactation or when breastfeeding not possible; electric pumps covered for rental up to purchase or purchase when mother/infant meets listed medical conditions.

PA documentationPrior authorization requests must be in mother's name, include Medicaid ID and estimated duration of need.

Cane definition

DefinitionCane: assistive device held in the hand used for support during ambulation (single, quad, or three-pronged; adjustable or fixed).

Coverage inclusionTips, handgrips and adjustment features are inclusive in rental/purchase and not reimbursed separately.

IndicationsCovered when condition/injury causes impaired ambulation and there is potential for ambulation.

Combination airway device definition

DefinitionCombination airway device: positive expiratory pressure/airway oscillation/intermittent flow acceleration device used to mobilize respiratory secretions in chronic lung conditions.

Age considerationMay not be appropriate for children under 6 years unless documented ability to use device correctly.

Coverage conditionPrior authorization required and purchase allowed when beneficiary has qualifying chronic lung diagnosis and can use/clean device.

Commode chair definition

DefinitionCommode chair: toileting aid for beneficiaries unable to use regular toilet facilities due to physical condition.

Coverage specificsCovered when prior authorized for rental up to purchase or purchase when indicated; detachable arms, heavy-duty/extra-wide models covered with documentation.

Raised toilet seatCovered when medical condition (e.g., post-hip surgery) prevents use of regular commode or when bedside commode not fit over toilet.

CPAP definition

DefinitionCPAP: non-invasive provision of air pressure through nasal administration and a flow generator to prevent collapse of oropharyngeal walls during sleep; apneas and hypopneas treated as 'respiratory events.'

Trial & suppliesCPAP rental covered for initial three (3) month trial when clinical event-rate/symptom criteria met; related supplies included in rental/purchase allowance.

Ownership after rentalAfter ten (10) consecutive months of rental including trial, beneficiary owns the CPAP.

Crutches definition

DefinitionCrutches: assistive devices used for support during ambulation; may be underarm or forearm, fixed or adjustable.

Customized crutchesCustomized crutches require prior authorization.

AccessoriesTips, handgrips and adjustment features included in rental/purchase and not reimbursed separately.

EMG biofeedback device definition

DefinitionEMG biofeedback device: equipment that detects, amplifies and displays physiological responses using surface electrodes and an amplifier converting signals to auditory/visual output.

Coverage trialCovered for rental up to three (3) months with recertification required when continued therapy prescribed; prior authorization required.

DocumentationProvider must document beneficiary's capability to use the device.

Cochlear implant / AOD definition

DefinitionCochlear implant / AOD: implantable and non-implantable auditory osseointegrated devices; repairs, external replacement parts, batteries and chargers covered when medically necessary and prior authorized.

Ordering clinicianItems must be ordered by qualified specialists (audiologist, otologist, otolaryngologist or other trained physician).

WarrantyManufacturer must provide minimum one (1) year warranty for all items.

Gait trainer definition

DefinitionGait trainer: device similar to a walker with wide-based frame and casters; may include seat or supports for users with balance/trunk control difficulties.

Coverage modelCovered when prior authorized for rental up to three (3) months then recertification when ordered by specialist with PT/OT evaluation.

Therapy requirementPT/OT evaluation (not employed by DME supplier) must document medical necessity and expected duration.

BGM definition

BGM definitionBlood glucose monitor (BGM): portable battery-operated meter for home use to determine blood glucose using reagent strips.

Coverage linkageBGMs covered for rental up to purchase or purchase when prior authorized and ordered by physician with documented diagnosis and ability to self-test.

Related suppliesTest strips, lancets, control solutions and replacement batteries listed under covered medical supplies.

CGM definition

CGM definitionContinuous glucose monitoring (CGM): DME used to detect trends and patterns in glucose levels; includes adjunctive and non-adjunctive types.

Supply bundleCGM supply allowance covers supplies as a bundle including disposable sensors and transmitter; separately billed supplies will not be covered.

Coverage conditionsMinimally invasive CGM covered when FDA-approved for home use, medically necessary, prior authorized and ordered by physician actively managing diabetes.

Hospital bed definition

DefinitionHospital bed: medical device with articulating frame allowing head/foot adjustment, headboard, footboard and mattress.

Total electric criteriaTotal electric beds require physician with relevant expertise, on-site OT/PT evaluation, two-year warranty, and no receipt of total electric bed within last five years.

Coverage modalitiesCovered when prior authorized and medically necessary for purchase or rental up to purchase amount.

NMES definition

DefinitionNMES: device transmitting electrical impulses to skin over selected muscle groups to treat disuse atrophy where nerve supply intact.

Coverage requirementCovered when prior authorized for rental only and ordered by orthopedist, neurologist or physiatrist with documented diagnosis and qualifying clinical situations.

User competencyBeneficiary and/or caregiver must demonstrate proper use and care of equipment.

Neuromuscular Electrical Stimulator (NMES) duplicate definition

Duplicate termNeuromuscular Electrical Stimulator (NMES) — same definition as NMES: transmits electrical impulses to skin over selected muscle groups to treat disuse atrophy when nerve supply intact.

Coverage notePrior authorization and clinician ordering restrictions apply (rental only).

Clinical qualifiersSpecific qualifying situations include casting/splinting, contractures, post-hip replacement until orthotic training, relaxation of spasms, re-education of muscle, increasing local circulation, or maintaining/increasing ROM.

Oxygen and Oxygen Related Equipment definition

DefinitionOxygen and related equipment: devices and systems (stationary/portable gaseous or liquid systems, concentrators, contents and accessories) that allow safe delivery of oxygen as DME.

Prior authorizationPrior authorization required before initiation and annually thereafter for oxygen services.

Billing & content rulesStationary monthly rental includes regulators, tubing, cannulas, humidifier, contents, backup equipment and maintenance; portable oxygen contents not billable in excess of one (1) unit/month.

Pacemaker monitor definition

DefinitionPacemaker monitor: self-contained device used in evaluation of a pacemaker by trans-telephonic monitoring converting generator pulse rate into ECG strip.

Coverage conditionPrior authorization required; rental up to purchase amount or purchase when indicated; ordered by physician and beneficiary must have implanted pacemaker and access to telephone.

User requirementBeneficiary/caregiver must be capable of performing monitoring function.

Pulse oximeter definition

DefinitionPulse oximeter: photoelectric apparatus determining oxygen in blood by measuring light transmitted through translucent part of skin.

Coverage distinctionsNon-recording oximeters and recording oximeters have specific clinical criteria and prior authorization requirements for coverage.

Ordering requirementMust be ordered by a physician and prior authorized for rental up to purchase or purchase when indicated.

Spacer / Aerosol-Holding Chamber definition

DefinitionSpacer / Aerosol-Holding Chamber: cylinder-shaped device (4–8 inches) with one-way valve attached to MDI to slow delivery and reduce oral deposition.

Coverage conditionCovered for purchase when ordered by a physician and beneficiary cannot coordinate MDI actuation and inhalation and meets diagnosis criteria.

Intended useUsed with a metered dose inhaler to improve medication delivery efficiency.

Home suction pump definition

DefinitionHome suction pump: lightweight, compact electric aspirator designed for upper respiratory suction for home use without technical supervision.

CoverageStationary and mobile suction pumps covered when prior authorized and ordered by physician with qualifying clinical indications; users must be trained.

ComponentsMobile units include rechargeable battery and charger, vehicle adapter, canister, connector and carrying case.

Traction equipment definition

DefinitionTraction equipment: devices used to apply pulling force to body part to minimize muscle spasms, align fractures, or increase joint space.

CoverageCovered when prior authorized for rental up to three (3) months then recertification; ordered by appropriate specialists and must be appropriate for home use.

Clinical qualifiersRequires radiographic verification for cervical/pelvic impairment or documented chronic pain unrelieved by other treatments.

TENS definition

DefinitionTENS: device delivering electrical current through skin electrodes to decrease perception of pain by inhibiting pain impulses or stimulating endorphin release.

CoverageCovered when prior authorized; rental up to purchase or purchase when indicated with specific trial and documentation requirements for acute and chronic pain.

Conductive garmentsCovered only if conventional electrodes are infeasible or contraindicated.

Transfer board definition

DefinitionTransfer board: wooden or plastic device used to transfer individuals from one surface to another to assist bed mobility.

Coverage criteriaCovered when prior authorized and ordered by a physician with qualifying mobility or caregiver lift limitations.

Use casesCovered when patient has decreased/absent lower extremity function, obesity preventing transfer, required by caregiver for bed mobility, or caregiver unable to lift patient.

Trapeze bar/equipment definition

DefinitionTrapeze bar/equipment: device (attached or freestanding) used to assist beneficiaries with truncal or lower extremity weakness to rise to sit, change position, or get in/out of bed.

Coverage distinctionsAttached trapeze covered when integral to a medically necessary hospital bed; freestanding trapeze covered only with non-hospital bed and beneficiary not renting/owning hospital bed.

Prior authorizationPrior authorization required and physician order necessary for coverage.

Transfer board duplicate definition

Duplicate termTransfer board: wooden/plastic device used to transfer individuals between surfaces; caregiver use permitted for bed mobility assistance.

Criteria summaryCovered when prior authorized and ordered by physician with one of listed mobility/caregiver conditions.

DocumentationProvider must maintain documentation supporting medical necessity and delivery records.

Ventilator definition

DefinitionVentilator: mechanical device used for artificial ventilation of the lungs.

Coverage modalityCovered for rental only when prior authorized and ordered by physician with qualifying clinical criteria (unable to maintain spontaneous respiration or safe gas levels).

Rental allowanceRental includes equipment, delivery, set-up, supplies, education, maintenance/repairs, labor/respiratory therapy visits, and servicing charges.

Walker definition

DefinitionWalker: assistive device providing wide base of support for ambulation/stance; may be rigid/folding, rolling or pickup type and height adjustable.

Coverage criteriaCovered when prior authorized and ordered by physician with specific functional criteria for rigid, pickup and wheeled walkers.

AccessoriesAttachments and seating accessories covered when medically necessary per detailed criteria.

Custom wedge seat insert definition

DefinitionCustom wedge seat insert: item made or substantially modified for a specific beneficiary used for positioning or pressure reduction and inserted into a seating system.

Coverage modalityPurchase only with prior authorization and ordered by specified physicians; requires PT/OT evaluation not employed by DME supplier.

ExclusionNot covered if existing custom seating provides similar benefits.

Wheelchair definition

DefinitionWheelchair: seating system designed to increase mobility for beneficiaries restricted by inability to ambulate or transfer.

Ordering & documentationPhysician order and prior authorization required; assessments, measurements and PT/OT involvement required for motorized/power/custom wheelchairs.

Frequency limitStandard and custom motorized/power wheelchairs limited to one per beneficiary every five (5) years.

Humidifier definition

DefinitionHumidifier: device, heated or non-heated, used to increase moisture content of the air; includes room humidifiers, vaporizers, warm mist humidifiers and HMEs.

CoverageCovered when ordered by physician, medically necessary and prior authorized for rental up to purchase or purchase.

ExclusionsNot covered for acute upper respiratory infections or isolated coughs/colds unrelated to another diagnosis.

Pressure reducing support surfaces definition

DefinitionPressure reducing support surfaces: surfaces designed for beneficiaries with limited/no mobility who are bed confined most/all day and prone to pressure ulcers.

Coverage conditionsCovered when ordered by physician, medically necessary and prior authorized for rental up to purchase or purchase; care plan and documentation required.

Replacement padsReplacement pressure pads for powered devices covered if beneficiary meets Rule 1.52 criteria.

Medical Supply CMN definition and requirements

CMN purposeMedical Supply Certificate of Medical Necessity (CMN) form completed by DME provider and signed by ordering physician within 30 days of delivery; retained in provider records and renewed per rules.

CMN contentCMN must include diagnosis, anticipated frequency/duration, requested quantity, detailed item descriptions including type/size and HCPCS codes, and physician signature.

Renewal frequencyMedical Supply CMN/prescription must be renewed every 12 months to be current (some incontinence CMNs recertify every 6 months unless chronic documented).

CGM supply bundle billing restriction

CGM bundle ruleContinuous glucose monitoring (CGM) supply allowance covers supplies as a bundled disposable sensors and transmitter; supplies billed separately will not be covered.

DME receiverDME receiver is covered if used alone or with a non-DME device; non-DME devices themselves are not covered.

Supply non-useIf a DME receiver is never used, the supply allowance will not be covered.

CMN content and renewal requirements

CMN contents and signatureA CMN must include diagnosis, anticipated frequency/duration, requested quantity, detailed item descriptions including HCPCS codes, and the ordering physician's signature; signature stamps or others' signatures not acceptable.

Renewal cadenceCMN must be renewed per applicable rules (medical supplies generally every 12 months; incontinence CMN every 6 months unless chronic documented for 12 months).

Retention and auditCMN retained in provider records and subject to review by Division of Medicaid; provider must provide copy to ordering clinician.

Provider responsibilities, documentation, and administrative rules

Note

Administrative note: maintenance contracts excluded; battery PA rules

Maintenance contracts and servicing fees are not covered; batteries and battery chargers require prior authorization and are covered for purchase only when associated with equipment—this administrative exclusion requires providers to avoid billing for maintenance contracts and to obtain PA for batteries/chargers when appropriate.

Do not submit claims for maintenance contracts or servicing fees (non-covered)
Obtain PA for batteries/chargers when associated with equipment purchase

Prior Authorization

Timely submission of PA for medical necessity review

Prior authorization must be submitted prior to or within thirty (30) days of delivery; the PA is a medical necessity review by the UM/QIO, the Division of Medicaid, or designated entity and protects beneficiaries from being billed if the provider delivers before authorization and approval is not given.

Prior Authorization

Repair PA must include cost estimate (including labor) and physician statement

Repair prior authorization must include an estimated repair cost that includes labor and a physician statement attesting to continued need for the DME or medical appliance; labor and delivery charges are included in repair costs and are not reimbursed separately.

Estimated repair cost (include labor)
Physician statement of continued need
Labor/delivery included in repair cost (not reimbursed separately)

Documentation Required

Required documentation for manual pricing requests

Manual pricing requests must identify the product name, product number, and manufacturer or distributor and provide documentation such as MSRP documentation or a dated manufacturer/distributor quote, or the provider's invoice (plus 20%) if no MSRP is available.

Submit product name, product number, and manufacturer/distributor
Provide MSRP documentation on letterhead, price list, catalog page, or dated quote
If no MSRP, submit provider invoice (invoice used plus 20% under hierarchy)

Documentation Required

CMN completion and 12-month renewal requirement

A Medical Supply Certificate of Medical Necessity (CMN) and/or prescription must be completed and signed by the ordering physician every twelve (12) months; the CMN must be retained in provider records and is considered current for twelve months from the physician's signature.

CMN/prescription signed by ordering physician every 12 months
CMN retained in provider records; considered current for 12 months

Billing Rule

30-day dispensing interval and beneficiary-request requirement

Providers must dispense medical supplies only in quantities to meet 30 days' needs; the beneficiary must request supplies monthly, supplies cannot be shipped automatically, and deliveries may be made no more than ten (10) calendar days before the expected end of the current supply.

Dispense only 30 days' supply
Beneficiary must request supplies monthly; no automatic shipments
Early delivery allowed up to 10 calendar days before expected end of supply

Supply quantities, frequency limits, and other numeric constraints

Reimbursement rates quick-reference

Purchased / Rental / Used benchmarksPurchased items = 80% of Medicare fee; Rental items = 10% of Division's allowable fee; Used items/repairs = 50% of Division's allowable fee.

SourceReimbursement percentages specified in Rule 1.4 reimbursement provisions.

ApplicationUsed across DME purchases, rentals and repair reimbursements unless manual pricing or special rules apply.

Initial rental/trial period (3 months)

3-month standard trialInitial rental/trial period commonly three (3) months for apnea monitors, BiPAP, CPAP, gait trainers, and EMG biofeedback.

Trial toward purchaseTrial fees apply toward maximum reimbursement for purchase and count against the ten (10) month rental cap.

Recertification needAfter initial 3-month trial, recertification or Compliance Certificate often required to continue rental.

Device replacement frequency limits — 5 years

5-year replacement benchmarkStandard replacement interval for wear and tear is every five (5) years unless extenuating circumstances; total electric hospital beds and electric lift mechanisms have specific five-year replacement limits.

Theft/fire/natural disasterReplacements outside the five-year interval allowed with documentation from law enforcement, fire department or appropriate authorities.

Provider responsibilityProvider must document and submit required evidence for replacement without trial when criteria met.

Portable oxygen contents billing limit

1 unit/month capPortable oxygen contents billing limit: not allowed to bill portable oxygen contents exceeding one (1) unit per month.

Unit definitionA unit is the quantity of oxygen the beneficiary uses per month; reimbursement same regardless of quantity dispensed.

Concurrent rental restrictionCannot bill rental of portable home compressor and rental of portable oxygen equipment (including contents) at the same time.

Wheelchair frequency limit — one per 5 years

One per five yearsWheelchairs (standard and custom motorized/power) limited to one (1) per beneficiary every five (5) years based on medical necessity.

Includes accessoriesFrequency limit applies to standard and custom motorized/power wheelchairs; accessories covered when physician-ordered and prior authorized.

Documentation requiredPT/OT evaluations, measurements and warranty information required to support replacement or new wheelchair requests.

Supply dispensing interval — 30 days

30-day dispensing ruleProviders must dispense supplies only in quantities to meet a beneficiary's needs for 30 days and beneficiary must request supplies monthly.

No automatic shipmentsSupplies cannot be shipped automatically; reoccurring deliveries require beneficiary request.

Early delivery allowanceRecurring supplies may be delivered up to 10 calendar days prior to expected end of current supply.

Early delivery allowance — up to 10 days

Up to 10 days earlySupplies provided on a reoccurring basis may be delivered no more than ten (10) calendar days prior to the expected end of the current supply.

ConditionEarly delivery applies only to recurring supplies when beneficiary requests and documentation supports timing.

Documentation requiredProvider must document delivery dates and that early delivery did not exceed the 10-day allowance.

Incontinence garment daily limit — 6 units/day

6 units/day without PAIncontinence garments — up to six (6) units per day for beneficiaries age three (3) and above without prior authorization.

Unit compositionOne unit equals one diaper, one pull-on, or one underpad; six units may be any combination.

PA for excessPrior authorization required for quantities exceeding six (6) units/day.

Personal sanitary wipes limit — 400/month

Personal sanitary wipesUp to 400 personal sanitary wipes per month.

ContextPart of incontinence supplies covered when medically necessary for beneficiaries age 3+.

PA for excessPrior authorization required for quantities exceeding the monthly limit.

Non-sterile gloves limit — 200 pairs/month

Non-sterile gloves capUp to 200 pairs of non-sterile gloves per month.

AssociationCovered as part of incontinence supplies when medically necessary for beneficiaries age 3+.

PA for excessPrior authorization required for quantities exceeding the monthly limit.

Non-medicated skin protectant — 2 units/month

Skin protectant limitNon-medicated skin protectant — up to two (2) units per month.

Coverage contextIncluded in incontinence supplies when medically necessary for beneficiaries age 3+.

Prior authorizationPrior authorization required for quantities exceeding the limit.

Manual pricing, POD, and invoice rules

Documentation Required

Manual pricing requests must include product/manufacturer details and supporting docs

When requesting manual pricing, include product name, product number, and manufacturer/distributor and attach required documentation (MSRP on manufacturer/distributor letterhead, dated quote, or invoice) as specified in the manual pricing hierarchy.

Provide product name, product number, manufacturer/distributor
Attach MSRP documentation or dated manufacturer/distributor quote
If no MSRP, submit invoice per hierarchy

Maximum recertification months for apnea monitors

Initial trialApnea monitors: initial three (3) month rental trial applies toward purchase.

Recertification up to 7 monthsAfter initial certification, apnea monitors may be recertified up to seven (7) additional months with new prescription or letter of medical necessity.

Total rental cap consistencyThe recertification window aligns with rental-to-purchase rules and the ten (10) month rental property vesting.

Supply dispensing interval (invoice/billing reference)

Dispensing interval repeatedProviders must only dispense supplies in quantities to meet a beneficiary's needs for thirty (30) days; beneficiary must request supplies each month and supplies cannot be shipped automatically.

Early delivery exceptionRecurring supplies may be delivered up to ten (10) calendar days before expected end of current supply.

Delivery documentationProvider must document detailed delivery elements including HCPCS codes, quantity, date beneficiary received item, and signature (exceptions during emergency).

Policy dates and revision log

2026-08-01EffectiveLatest

Policy effective date as stated in header-level metadata.

2025-01-01Last Review

Most recent documented review date as captured in header-level metadata.

Policy Summary

PayerMississippi Division of Medicaid

PolicyDurable Medical Equipment, Medical Appliances and Medical Supplies (DMEPOS)

Policy CodePolicy N/A

Change TypeMinor / Administrative (no material coverage changes)

Effective DateAug 1, 2026

Last ReviewJan 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization before or within 30 days of delivery for items requiring medical necessity review.

SourceLink

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