Durable Medical Equipment (DME) — Coverage Criteria
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Defines prior authorization, medical necessity, and coverage principles for standard and nonstandard durable medical equipment (DME) used in the home or community; applies to providers submitting DME requests for Northwood members.
No material clinical or coverage changes in this revision.
Coverage Criteria
General coverage criteria
Covered when ALL of the following are met:
Based on the policy definition of standard DME, prior authorization requirement, cost‑effectiveness expectation, and documentation requirements.
Nonstandard DME — Authorization criteria (case‑by‑case)
Nonstandard DME may be authorized when ALL of the following are met:
Nonstandard items are reviewed case‑by‑case and authorized only when reasonable and necessary.
Requests for DME and any associated accessories or features are considered not reasonable and necessary when they meet any of the following conditions: the item contains features not required for the member's condition; the item does not meet the policy's coverage criteria or specific product criteria; the equipment is primarily nonmedical in nature (used primarily and customarily for a nonmedical purpose); the request is made for convenience purposes; the item contains nonfunctional or aesthetic features; a feasible, medically appropriate standard alternative exists; the item serves essentially the same purpose as standard equipment; the item is disproportionate to the therapeutic benefit expected from standard equipment; or the item is experimental or investigational.
Certain situations are explicitly not eligible for reimbursement: continued rental or purchase of a DME item that is no longer needed or in use by the member for whom it was originally authorized; repair, maintenance, or replacement of rental equipment (these costs are included in the rental price); and when another source of coverage applies (for example, homeowner's, rental, automobile, liability, or other insurance ).
Items that are primarily nonmedical, supplied for convenience or aesthetic reasons, or that duplicate the function of standard equipment are considered not reasonable and necessary and therefore not medically necessary for coverage. Nonstandard features must be clinically justified and shown to be required for the member; otherwise the nonmedical or duplicative components will not be covered.
Provider Actions and Requirements
Prior authorization and prescription required
All DME requires prior authorization and must be prescribed by the treating practitioner.
Use most cost‑effective / justify nonstandard items
Coverage is limited to the most cost‑effective DME that meets the member's medical needs; nonstandard items (those with additional features that increase cost) must be justified and are reviewed case‑by‑case when a medically appropriate standard alternative does not exist.
Submit clinical documentation with requests
The treating practitioner must submit clinical information documenting the need for the DME and any associated accessories or features; for nonstandard requests the practitioner must explain why standard equipment does not meet the member's medical needs.
Document affirmative member contact before refills
Suppliers must contact the member or designee and document an affirmative response prior to dispensing refills; contact must occur no sooner than 30 calendar days before the expected end of current supply and delivery no sooner than 10 calendar days before expected end.
- Do not automatically ship refills; ensure refilled item remains reasonable and necessary.
- Document affirmative member/designee contact prior to dispensing.
Denial triggers for unreasonable or unnecessary DME
Requests will be denied when the item or features are not required for the member's condition, are primarily nonmedical or requested for convenience/aesthetic reasons, duplicate standard equipment, are disproportionate to expected therapeutic benefit, deemed experimental/investigational, or otherwise do not meet policy criteria.
- Features not required for condition
- Primarily nonmedical, convenience, or aesthetic requests
- Duplicates or serves same purpose as standard equipment
- Disproportionate to therapeutic benefit
- Experimental or investigational items
Denial for undocumented refills
Refills delivered without a valid, documented refill request and an affirmative member/designee response will be denied as not reasonable and necessary; suppliers must not deliver refills without a refill request and affirmative response.
- Items delivered without a valid, documented refill request will be denied.
- Suppliers must not deliver quantities exceeding expected utilization and must verify atypical utilization with the treating practitioner.
Definitions
Medical Necessity
DME medical necessity
Medical necessity requires demonstration that the DME is medically required and the most cost‑effective option that meets the member's needs.
Applies to both standard and nonstandard DME; nonstandard features require additional justification that standard equipment is inadequate.
Rental and Purchase Rules
| Item type | Rental rules | Purchase rules / purchased equipment |
|---|---|---|
| Standard DME | Rental of standard DME is eligible for coverage when the item is determined to be reasonable and necessary. | Purchase of standard DME is eligible for coverage when the item is determined to be reasonable and necessary. Medical supplies required to make the DME medically effective are eligible if the DME is reasonable and necessary. Coverage for repairs/maintenance of purchased equipment may be available unless covered by a manufacturer's warranty or purchase agreement; replacement may be covered when replacement is more cost effective than repair. |
| Nonstandard DME (items with additional features beyond standard) | Nonstandard DME may be considered for rental only when the nonstandard features are reasonable and necessary and clinical information documents why standard equipment does not meet the member's needs. | For purchased nonstandard DME, only the equipment and features determined to be reasonable and necessary will be covered; clinical justification must document why a medically appropriate standard alternative does not meet the member's needs. Repairs/maintenance and replacement follow the same principles as purchased equipment (coverage may be available unless a warranty/purchase agreement applies; replacement may be covered if more cost effective than repair). |
| Items primarily nonmedical, convenience/aesthetic features, duplicates of standard equipment, or experimental items | Not eligible for rental coverage because such requests are considered not reasonable and necessary (features not required for the member's condition, requested for convenience or aesthetic reasons, duplicate standard equipment, or experimental). | Not eligible for purchase coverage/reimbursement in these situations: continued rental/purchase no longer needed by the original authorized member; repair/maintenance of rental equipment (rental includes maintenance); items primarily nonmedical or experimental; when another coverage source is available. |
Replacement and Purchased Equipment
Documentation Requirements
Clinical justification required with prior authorization
Treating practitioners must submit clinical information documenting the need for the DME and any associated accessories or features with the prior authorization; for nonstandard features the submission must explain why standard equipment does not meet the member's needs.
Document affirmative refill request and confirm before shipping
Suppliers must document an affirmative member or designee contact prior to dispensing refills and must not ship refills without a valid refill request and affirmative response; contact must occur no sooner than 30 days before the expected end of supply and delivery no sooner than 10 days prior.
- Contact no sooner than 30 calendar days before expected end of current supply.
- Deliver refills no sooner than 10 calendar days before expected end of supply.
- Do not ship refills without a documented refill request and affirmative member response.
Not Covered
NOT COVERED: Repair, maintenance, or replacement of rental equipment when those services are included in the rental agreement; equipment that is primarily nonmedical; and items requested solely for convenience or for aesthetic purposes. Items that are experimental/investigational or are covered by another insurance source are also not covered.
Background
BACKGROUND: Durable medical equipment (DME) are reusable medical devices intended for use in the home or community to provide therapeutic benefit for members with illness or injury. DME must be primarily medical in nature and appropriate for home use; examples include wheelchairs, hospital beds, traction equipment, canes, crutches, walkers, and oxygen.
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