Durable Medical Equipment (DME) coverage criteria
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Defines Northwood's coverage, medical necessity criteria, prior authorization, and administrative rules for standard and nonstandard durable medical equipment and recurring DMEPOS supplies for members.
Added refill requirements for DMEPOS items and supplies provided on a recurring basis.
Added that DME is considered not reasonable and necessary if the item is deemed experimental/investigational.
Coverage Criteria
Medical necessity: Initial coverage
Covered when ALL of the following are met
Supported by the policy definition of standard DME.
Clinical documentation must justify need and any nonstandard features (see nonstandard review).
If a purchased/rented item has more nonstandard features than required, only reasonable and necessary parts/features are covered.
The following types of items and features are considered not reasonable and necessary and are excluded from coverage: items that are primarily nonmedical in nature or used customarily for nonmedical purposes; items requested for convenience or for purely aesthetic reasons; and features that are not required for the member’s condition or for the proper functioning of the base item. Coverage is also denied when a requested item duplicates the function of a medically appropriate standard alternative, when the item is disproportionate to expected therapeutic benefit, or when the item is considered experimental or investigational.
Requests will be considered not reasonable and necessary when they are for the continued rental or purchase of DME that is no longer needed or in use by the member for whom it was originally authorized. Additionally, refill deliveries that occur without a valid, documented refill request and an affirmative member response will be denied as not reasonable and necessary.
Coding and Refill Timing
Provider Actions & Authorization
Prior authorization required
All DME requires prior authorization and must be prescribed by the treating practitioner.
Standard-first preference
Coverage favors the most cost‑effective standard DME that meets the member's medical needs; nonstandard items and additional features are more expensive than the standard item and will be reviewed on a case‑by‑case basis and require justification when a standard alternative exists.
- Nonstandard DME has additional features that increase cost and will be reviewed individually.
- Provider must document why a standard item is not medically appropriate when requesting nonstandard features.
Clinical documentation required
The treating practitioner must submit clinical information documenting the medical need for the DME and any associated accessories or features; when requesting nonstandard equipment, include reasons why the standard equipment does not meet the member's needs.
Triggers for denial
Denials may be triggered if refills are delivered without a documented refill request and an affirmative member response; items that are experimental/investigational or primarily nonmedical, requested for convenience or aesthetic features, or for which a medically appropriate standard alternative exists may also be denied.
- Refill deliveries made without a valid, documented refill request and affirmative response will be denied as not reasonable and necessary.
- Items deemed experimental/investigational or primarily nonmedical are considered not reasonable and necessary.
Background
Durable medical equipment (DME) refers to items of medical equipment, owned or rented, used in a member’s home or community to provide therapeutic benefit. Examples include wheelchairs, hospital beds, canes, walkers and oxygen. To be covered the DME must withstand repeated use, be appropriate for home or community use (private residence, relative’s home, retirement home), and have a primary medical use. Coverage decisions are based on clinical information and whether the item is reasonable and necessary and represents the most cost-effective standard option that meets the member’s needs. Nonstandard items or added features that increase cost require clinical justification showing that standard equipment is not appropriate.
Definitions
Medical Necessity Rules
DME medical necessity
Covered when ALL of the following are met
See standard DME definition and place-of-service guidance.
Items primarily nonmedical, requested for convenience or aesthetic features, or containing nonrequired features are not reasonable and necessary.
Nonstandard DME will be reviewed case-by-case; providers must document why standard equipment does not meet needs.
Rental and Purchase Rules
| Equipment | Rule |
|---|---|
| Standard DME | |
| The rental or purchase of standard DME is eligible for coverage if determined to be reasonable and necessary; when purchased or rented items include more nonstandard features than required, only the equipment and features determined to be reasonable and necessary will be covered. |
| Equipment | Coverage status | Rule / rationale |
|---|---|---|
| Rental equipment | ||
| not_covered | ||
| Repair, maintenance, or replacement of rental equipment is not separately reimbursable because the rental price includes maintenance; continued rental or purchase of an item no longer needed is not considered reasonable and necessary. |
Replacement Rules
Documentation Requirements
Clinical justification required with prior authorization request
When submitting a prior authorization request, the treating practitioner must include clinical justification documenting the need for the DME and any accessories/features; for nonstandard DME, explicitly state why standard equipment is not appropriate for the member.
Not Covered
The following are explicitly not covered: repair, maintenance, or replacement of rental equipment (the rental price includes maintenance); equipment that is primarily nonmedical; items or features requested for convenience or aesthetic purposes; features not required for the member’s condition; experimental or investigational items; and items for which another source of coverage (homeowner, rental, automobile, liability or other insurance) is available.
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