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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyModa Health DME Coverage & Prior Auth Policy Updat…
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    CurrentModa HealthPolicy N/A

    Durable Medical Equipment (DME) General Policy

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    Defines Moda Health's coverage, medical necessity criteria, documentation and exclusions for durable medical equipment supplied for home use; applies to Moda Health members and providers submitting DME requests for benefit determination.

    Policy Summary
    PayerModa Health
    PolicyDurable Medical Equipment (DME) General Policy
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateFeb 1, 2026
    Last ReviewJan 28, 2026
    Next Review DateJan 28, 2026
    Key ActionSubmit a physician's order and required medical records with prior authorization requests.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    AllDME covered when ALL listed criteria are met
    Examples listedCommon DME types referenced
    SeveralExplicit non-covered categories
    Physician orderPreauthorization requires

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

    Coverage Criteria and Limitations

    General medical necessity criteria (CWQI HCS-0025)

    Covered when ALL of the following are met:

    General DME medical necessity: a. The equipment provides therapeutic benefit to a member with certain medical conditions and/or illness. b. The DME is prescribed by a physician within the scope of his/her practice. c. The DME does not serve primarily as a comfort or convenience item. d. The DME meets the criteria outlined in specific DME policy if established. e. The DME that is approved is the least costly item to meet the patient's medical need. f. The equipment can withstand repeated use (i.e., could normally be rented and used by successive patients). g. For specific DME criteria, refer to NCD 280.1 and Noridian DME guidelines.

    General DME medical necessity

    General criteria: The item meets Moda Health's general DME medical necessity requirements: provides therapeutic benefit; prescribed by a physician within scope of practice; not primarily for comfort or convenience; meets any applicable specific DME policy criteria; is the least costly item that meets the patient's medical need; and can withstand repeated use.

    Maintenance, repair, and replacement

    Maintenance, repair, and replacement covered on individual consideration when:

    Repair/Replacement Conditions: a. Repair or maintenance of purchased equipment may be covered on an individual basis when necessary to make the equipment usable. b. Replacement of rental equipment may be recommended when the rented item is irreparably damaged, or when replacement is required during repair and/or maintenance. c. Replacement or repair of an item that has been misused or abused is the responsibility of the member. d. Moda Health has the option to repair or purchase a new DME.

    Optional or ancillary features and upgrades that are primarily for convenience or aesthetic purposes are not covered. Examples include decorative items and specialty materials (for example, custom-colored wheels or lights), accessory items such as cup holders, backpacks, or extra batteries, and upgrades for recreational or racing use. Coverage is also not provided for items that do not provide a therapeutic benefit (for example, car seats) or for equipment that is prescribed outside the physician’s scope of practice. (See policy lists of noncovered examples.)

    Items that are primarily for comfort, convenience, leisure, sports, or environmental modification are not medically necessary and therefore not covered. Electronic devices with multiple general-purpose uses (such as laptops, tablets, and smartphones) do not meet the definition of DME unless the specific software/application is reviewed and approved by Medical Management and the Medical Director; even then, installation, technical support, adapters, and monthly service fees (internet/data/cellular) are not separately reimbursable. Wheelchair accessories or options intended mainly to enable leisure, recreational or outdoor adaptation are generally excluded.

    Coding and Billing References

    Covered CPT/HCPCS CodesHCPCS
    No codes listed
    Applicable Diagnosis CodesICD-10
    No codes listed
    Medicare jurisdictions / Part B applicability
    Applicability to Medicare Part B / NCD/LCDCompliance with applicable National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) is required; additional indications may be covered at the discretion of the health plan.
    Jurisdiction referencesMedicare Part B covered diagnosis codes and applicable NCD/LCDs are referenced by contractor jurisdictions (example jurisdictions: 5, 8, 1).
    Where to find NCD/LCD guidanceCMS Medicare Coverage Database: http://www.cms.gov/medicare-coverage-database/search/advanced-search.aspx (use to identify applicable NCDs/LCDs for specific DME items).
    Medicare contractor mappingNCD/LCD documents and MAC jurisdiction mapping are used to determine applicability (examples: Noridian Healthcare Solutions, LLC listed for specific jurisdictions).

    Prior Authorization, Documentation, and Provider Responsibilities

    Prior Authorization

    Prior authorization required — physician order and possible medical records

    Prior authorization is required for DME and must be supported by a physician's order; Moda Health may request medical records to determine medical necessity when reviewing the request.

    • Prior authorization is required for DME coverage determination.
    • A physician's order must accompany the preauthorization request.
    • Moda Health may request medical records to determine medical necessity.
    Step Therapy

    Provide the least costly appropriate item

    When approved, the DME supplied must be the least costly item that meets the patient's medical need.

    • Covered DME must be the least costly item to meet the patient's medical need as stated in the criteria.
    Documentation Required

    Submit medical records and include complete supporting documentation

    Moda Health may request medical records as part of the prior authorization review; letters of support can be useful but are not sufficient unless they include all required specific information for the requested DME.

    • Submit complete medical records when requested to support medical necessity.
    • Letters of support/explanation may be helpful but must include all specific required information to be sufficient.
    • Additional item-specific information may be requested for separate DME criteria.
    Billing Rule

    Include physician order; note rental fee coverage of ancillary services

    A physician's order is required for preauthorization of DME; rental fees cover maintenance, repairs, replacement, supplies and accessories and delivery/set‑up/education are not separately reimbursable.

    • Include the physician's order with the prior authorization request.
    • Understand that rental fees include maintenance, repairs, replacement, supplies and accessories.
    • Equipment delivery, set‑up, patient/family education, and nursing visits are not eligible for separate reimbursement.
    Denial Risk

    Triggers for denial or noncoverage

    Coverage will be denied or not provided when the DME is primarily for convenience or comfort, is experimental or non‑FDA approved, not prescribed by a physician within scope, prescribed for other than intended use, used in a facility expected to provide the item, part of a home exercise program, abused or used beyond specifications, or primarily for custodial care.

    • Optional or ancillary features primarily for convenience (decorative items, specialty materials, cup holders, backpacks) are not covered.
    • Devices that do not provide therapeutic benefit, experimental equipment, or non‑FDA approved equipment are not covered.
    • Items not prescribed by a physician within the scope of practice, prescribed for other than intended use, or used in a facility expected to provide the item are not covered.
    • DME primarily assisting custodial care or items part of a home exercise program are not covered.
    • Equipment that was abused or used beyond specifications is the member's responsibility and not covered.

    Background

    Durable Medical Equipment (DME) is equipment prescribed for use in the home that provides a therapeutic benefit, is designed to withstand repeated use, and is primarily and customarily used to serve a medical purpose. Typical examples referenced in the policy include wheelchairs (manual and power), hospital beds, oxygen and ventilator equipment, CPAP devices, prosthetics, pressure mattresses, and related supplies. Moda Health follows applicable CMS/Noridian guidance where Moda‑specific criteria do not apply and expects DME to be prescribed by a physician within the scope of their practice to meet a documented medical need.

    Definitions

    Durable Medical Equipment (DME) — key attributes and definition
    DefinitionDurable Medical Equipment (DME) is any equipment for home use that provides therapeutic benefit, can withstand repeated use, and is primarily and customarily used to serve a medical purpose.
    Common examplesWheelchairs (manual and electric), hospital beds, traction equipment, canes, crutches, walkers, ventilators, oxygen equipment, monitors, pressure mattresses, nebulizers, prosthetics, CPAP, phototherapy equipment.
    Coverage conditionCovered when determined medically necessary and when the item is a covered benefit under the member's health plan.
    Rental vs purchaseModa Health will maintain the option to rent or purchase DME; rental fees cover maintenance, repairs, replacement, supplies and accessories.

    Medical Necessity Standards

    General DME medical necessity

    Primary necessity conditions: Equipment is medically necessary only when it provides therapeutic benefit; is prescribed by a physician within scope; is not primarily for comfort/convenience; meets any specific DME policy criteria; is the least costly appropriate item; and is durable for repeated use.

    Rental and Purchase Rules

    RentalPurchase
    Moda Health will maintain the option to rent or purchase DME; rental fees cover maintenance, repairs, replacement, supplies and accessories.Moda Health may purchase DME; repair or maintenance of purchased equipment may be covered on an individual basis when necessary to make the equipment usable.
    Rental fees include maintenance, repairs, replacement, supplies and accessories; delivery, set‑up, education, and nursing visits are not separately reimbursable.Replacement or repair of purchased items that have been misused or abused is the member's responsibility; Moda Health has the option to repair or purchase new DME.

    Replacement and Replacement Intervals

    Rental or purchased DME — replacement
    Replacement interval policyReplacement intervals for rental or purchased DME are determined on a case‑by‑case basis; no fixed interval is stated in the policy.
    When replacement is recommendedReplacement of rental equipment may be recommended when the rented item is irreparably damaged or if replacement is required during repair/maintenance of the item.
    Repair vs member responsibilityRepair or maintenance of purchased equipment may be covered individually to make equipment usable; replacement or repair of items misused or abused is the member's responsibility.
    Moda Health discretionModa Health has the option to repair or purchase new DME as part of individual consideration decisions.

    Required Documentation for Authorization

    Documentation Required

    Include medical records and item‑specific information with prior authorization

    When submitting a prior authorization request, include medical records and any additional item‑specific information Moda may request; letters of support may be useful but must contain all required specifics to be sufficient.

    • Attach relevant medical records when requested for medical necessity review.
    • Provide item‑specific details if requested for separate DME criteria.
    • Letters of support should include all required information; otherwise Moda may request full records.
    Prior Authorization

    Physician order required with prior authorization request

    A physician's order must accompany the prior authorization request for DME; preauthorization will not be processed without it.

    • Ensure the prescribing physician's order is included with the PA submission.

    Exclusions and Non-Covered Items

    Moda Health does not cover ancillary or optional convenience features, decorative or specialty materials, and accessory items that are not necessary to achieve the prescribed therapeutic function. Examples explicitly excluded include decorative wheelchair upgrades, specialty wheels or lights, personal backpacks/baskets, cup holders, and dual‑mode or supplemental chargers beyond what is included with the base device. Environmental enhancement devices (for example, air conditioners, humidifiers), experimental or non‑FDA‑approved equipment, items prescribed for non‑intended uses, and devices primarily assisting custodial care or activities of daily living are also not covered. Electronic devices with multiple uses (laptops, tablets, smartphones) are not DME unless the software is separately reviewed and approved, and service or connectivity fees are not reimbursable.

    Policy Summary
    PayerModa Health
    PolicyDurable Medical Equipment (DME) General Policy
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateFeb 1, 2026
    Last ReviewJan 28, 2026
    Next Review DateJan 28, 2026
    Key ActionSubmit a physician's order and required medical records with prior authorization requests.
    SourceLink
    On This Page
    Coverage Criteria and LimitationsCoding and Billing ReferencesPrior Authorization, Documentation, and Provider ResponsibilitiesBackgroundDefinitionsMedical Necessity StandardsRental and Purchase RulesReplacement and Replacement IntervalsRequired Documentation for AuthorizationExclusions and Non-Covered Items