Neighborhood Health Plan RI Durable Medical Equipment Coverage

Coverage Criteria

Medical necessity, documentation, and replacement criteria

Covered when ALL of the following are met

General coverage and medical necessity: Equipment is ordered by a physician; medically necessary to treat the member's condition, improve function, or maintain health; must be provided in the most cost‑effective, appropriate setting and used in the home/community by an authorized member

Refer to required documentation elements and face-to-face encounter timing

Face-to-face and documentation: Face-to-face encounter (in-person or telehealth) with certifying physician or authorized NPP within 6 months prior to the order and related to the primary reason for DMEPOS; prescription/order includes member name and DOB, ICD-10-CM code, detailed description of DMEPOS (quantity, special options, add-ons), length of need (start and end dates), prescribing provider name/address/NPI, and provider signature/date; Certificate of Medical Necessity and supporting medical records included with prior authorization when applicable

Order and Certificate of Medical Necessity are valid for 12 months from date of issue

Replacement criteria: Replacement covered when any ONE of the following applies: a new item is required due to a change in the member's medical condition; the equipment no longer meets functional needs due to physical changes (e.g., skeletal growth or significant weight changes); cost to repair exceeds 60% of replacement cost; an upgrade is required and the manufacturer no longer supports the itemrepair >60%

Per CMS guidance typical reasonable useful lifetime (RUL) is ~5 years

General coverage exclusions: Durable Medical Equipment (DME) and related supplies (other than personal needs items) are not covered when furnished to members residing in a Nursing Facility or an Intermediate Care Facility (ICF). Deluxe or enhanced DME items are excluded from coverage. Delivery and setup are included in the rental or purchase fee and are not separately reimbursable. Repairs and supplies for rental equipment are included in the rental allowance (except CPAP/BiPAP supplies). Routine maintenance (periodic servicing such as testing, cleaning, regulating, and checking) is not covered, and repair/replacement covered by the manufacturer warranty is the manufacturer’s responsibility and coordinated by the DME provider.

Duplicate or caregiver-related items: Duplicate DME items intended for use in multiple locations and items primarily intended to assist a caregiver rather than meet the member’s medical needs are not covered. Purchase, repair, or replacement resulting from member abuse or loss/theft is not covered unless supporting documentation (continuing medical necessity, description of the item, and police/fire/insurance report if applicable) is provided.

This medical policy is provided for informational purposes only and is not a guarantee of payment. Benefits and eligibility are determined by the member’s coverage plan, and the member’s plan will supersede the provisions of this policy. For member-specific benefits and eligibility information, contact Member Services.

Items and supplies that function primarily for the convenience of the member are not covered. Examples called out in the policy include items purchased or supplied primarily for convenience rather than to meet a documented medical need; such items must be distinguished from equipment that is medically necessary to treat a condition, improve function, or maintain health.

Coding and Quantity Rules

Incontinence product HCPCS codes with quantity rulesHCPCSCovered

T4521-T4535	Adult, pediatric, and youth sized disposable incontinence products (briefs/liners/pull-ups)
T4543-T4544	Adult, pediatric, and youth sized disposable incontinence products (additional codes)
T4541-T4542	Incontinence product, disposable underpad, large and/or small

Incontinence product authorization thresholds

Authorization threshold — briefs/liners/pull-upsAuthorization required when quantity >192 per month for any combination of briefs, liners, and/or pull-ups; requests >192/month must include medical necessity documentation explaining clinical rationale.

Authorization threshold — underpadsAuthorization required when quantity >150 per month for any combination of disposable underpads; requests >150/month must include medical necessity documentation explaining clinical rationale.

Plan maximum monthly quantityPlan maximum monthly quantity limit is 300 for incontinence products and underpads combined, inclusive of any medically necessary increases.

Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization Submission Requirement

Prior Authorization Required: When prior authorization is required for a DMEPOS service, in‑network DME suppliers must submit a completed Prior Authorization Request form to Integra. Out‑of‑network DME suppliers must submit prior authorization requests directly to Neighborhood Health Plan of Rhode Island. The completed form must be signed and dated by the DME supplier provider attesting to the accuracy of the request.

In‑network submissions: Integra
Out‑of‑network submissions: Neighborhood Health Plan of Rhode Island
Prior Authorization Request form must be signed and dated by the DME supplier

Note

Prior Authorization and Eligibility Note

Prior authorization is an informational and administrative requirement only; it does not guarantee coverage or payment. Providers should always verify member benefits, eligibility, and specific plan requirements before furnishing DMEPOS.

Repair, Replacement, and Medical Necessity

Repair and replacement

Repair coverage: Repair is covered when the original equipment was ordered by a physician, the equipment remains medically necessary, and the repair is medically necessary to make the equipment serviceable

Rental is covered while a covered DME item is being repaired unless the item is under manufacturer warranty; repairs to DME already replaced with the same or similar item are not covered (duplication)

Replacement coverage: Replacement is covered when a new order by a physician is present and any ONE of the following applies: change in member's medical condition; equipment no longer meets functional needs due to growth or significant weight change; cost to repair exceeds 60% of replacement cost; upgrade required and manufacturer no longer provides needed supportrepair >60%

For capped rental items (e.g., wheelchairs), after title transfer the supplier may be required to replace equipment if accumulated repair cost exceeds the specified threshold

Rental, Purchase, and Rental-To-Purchase Rules

Rule	Details
Rent-to-purchase period
DME rentals are for a continuous 10-month period; after ten consecutive months title transfers (considered paid up) and charges beyond ten months are non-billable.

Item / Topic	Policy / Rule
Monthly rental pricing
Rental priced at one‑tenth (1/10) of the purchase price per month; Neighborhood's rental allowance will never exceed the purchase allowance.
Frequent serviced / continuous rental items
Items classified by CMS as Frequent Serviced Items are treated as continuous rentals, priced at the rental allowance, and excluded from the 10‑month rent‑to‑purchase cap.
Change of supplier during rental
A change to another DME supplier during the 10‑month rental period does not start a new 10‑month period; the new supplier may bill remaining rental months and the supplier providing the item in the 10th month is responsible for supplying and for maintenance after title transfers.
Capped rental items (e.g., wheelchairs) — replacement after title transfer
For capped rental items, once title transfers (after the specified rental period) the supplier may be required to replace equipment if accumulated repair costs exceed the applicable threshold (repair cost >60% of replacement may trigger replacement).

Replacement Considerations and Useful Lifetime

General DME typical reasonable useful lifetime (RUL)

Typical RULPer CMS guidance, the reasonable useful lifetime (RUL) of rental equipment is typically 5 years.

Repair-cost triggerReplacement may be required when cost to repair exceeds 60% of the cost of a replacement item.

Manufacturer supportReplacement is considered when an upgrade is required and the manufacturer no longer provides needed support for the item.

Documentation Requirements

Billing Rule

Required prescription/order elements for medical necessity and PA

Prescriptions and orders submitted for medical necessity determination or prior authorization must include the member's name and date of birth, the applicable ICD-10-CM code, a detailed description of the item (including quantity, special options, and add‑ons), and the length of need (start and end dates).

Member name and Date of Birth.
ICD-10-CM diagnosis code.
Detailed item description with quantity, special options, and add‑ons.
Length of need including start and end dates.

Items Not Covered

Not covered items include: deluxe/enhanced DME, items primarily for member convenience, duplicate items for use in multiple locations, and items intended mainly for caregiver convenience. Routine maintenance (defined as testing, cleaning, regulating, and checking) is excluded. Repairs or replacements covered under manufacturer warranty are the manufacturer’s responsibility and not payable under this policy. Additionally, DME and supplies (other than personal needs items) provided to members in a Nursing Facility or ICF are not covered; delivery and setup are included in the rental/purchase fee and are not separately reimbursed.

Background

Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) are items and related supplies that are intended to be durable, primarily medical in purpose, and appropriate for use in the home or community to treat medical conditions, improve function, or maintain health. Examples include wheelchairs, hospital beds, walkers, oxygen equipment, CPAP/BiPAP systems (and certain associated supplies), orthotics, prosthetics, and incontinence supplies. Face-to-face evaluation and supporting clinical documentation are required to demonstrate the medical necessity of DMEPOS and how the equipment will address functional limitations, safety, mobility, activities of daily living, respiratory function, or other health outcomes.

Definitions

Durable Medical Equipment, Orthotics, Prosthetics, and Supplies (DMEPOS)

DMEPOS definitionItems and services that are medically necessary to treat a medical condition, improve function, or maintain health; includes durable medical equipment, prosthetics, orthotics, and supplies.

Scope — care settingIntended for use to support treatment, function, or health maintenance in the home/community setting.

IncludesDurable medical equipment, prosthetics, orthotics, and related supplies.

Durable Medical Equipment (DME) — examples and scope

DME definitionEquipment that can withstand repeated use, is primarily for medical purposes, and is appropriate for use in the home (examples: wheelchairs, hospital beds, oxygen equipment).

Intended use