CurrentPremera BluecrossPolicy N/A

Durable Medical Equipment (DME) coverage

Defines medical necessity, coverage, exclusions, documentation, and coding for durable medical equipment (DME) for Premera Bluecross plan determinations; intended for providers and DME suppliers.

Policy Summary

PayerPremera Bluecross

PolicyDurable Medical Equipment (DME) coverage

Policy CodePolicy N/A

Change TypeNo material clinical or coverage changes

Effective DateFeb 1, 2026

Next Review DateFeb 1, 2026

Key ActionProvide face-to-face clinical evaluation, an order stating therapeutic purpose, documentation of functional impairment related to ADLs, and prior trial of less complex devices when applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

AllMedical necessity rule

6-12 monthsLong-term use

E0150,E0152,E1399Named HCPCS

SpecificNot-covered additions

NationalMedicare guidance

Coverage criteria and exclusions

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Medical necessity — general DME

Durable medical equipment may be considered medically necessary when ALL of the following are met:

DME medical necessity: The individual has a documented physical functional impairment or disability due to disease, trauma, congenital anomaly, or prior therapeutic intervention and requires accommodation for basic activities of daily living (ADLs) that can be met by using the requested DME item; Documentation in the medical record contains a clinical assessment and rationale for the requested DME item (see Documentation Requirements); The DME is prescribed by a health care practitioner; The piece of equipment meets the definition of durable medical equipment (DME); The requested DME item is not considered investigational or unsafe by a regulatory agency, and is not excluded by plan benefits or considered a contractual exclusion.

All conditions required

Covered and Not Covered Statements

Policy-level coverage stance and evidence notes

Evidence-based exclusions: A device that manipulates or alters auditory feedback (altered auditory feedback, e.g., delayed auditory feedback or frequency-shifted auditory feedback) used to help with speech dysfluency or stuttering: there is insufficient evidence to conclude these devices are effective for treatment of stuttering or dysfluency.

from evidence statement

Non-covered additions: Remote hand-held devices for intermittent monitoring of intraocular pressure (e.g., iCare HOME2), battery-powered wheeled walkers, and combination wheeled walker and wheelchair devices are listed in the policy history as non-covered or investigational items and are considered not medically necessary under this guideline where applicable.

from policy history entries

Accessory add-ons, upgrades, or deluxe features are not covered when a basic (standard) DME item meets the member's documented functional needs. Requests for comfort or convenience items added to standard equipment will be reviewed against the member's clinical record, but are typically excluded. The policy specifically excludes deluxe equipment when standard equipment is adequate and excludes multiple-function hardware not primarily intended for medical use (e.g., desktop/laptop computers, PDAs, smartphones, tablets).

Duplicate devices that meet the same functional need (for example, a rolling walker when the member has a properly fitted cane) and redundant or back-up DME items (more than one of the same item, such as a second device for travel or a second residence) are considered not medically necessary. Where an item is both an accessory/upgrade and duplicates an available standard device, coverage is not supported.

When a DME item is addressed in another policy or the member's benefit booklet, providers should follow the specific policy/contract guidance; purchase versus rental guidance (purchase allowed if less expensive than rental) and repair/replacement provisions are described elsewhere in related policies.

Requests for duplicate, redundant, or back-up equipment are considered not medically necessary unless the medical record documents a clear, medically required reason why more than one device is needed to meet basic ADLs. The policy gives the example of duplicate mobility devices meeting the same functional need as a denial trigger.

Specific items listed in the policy as non-covered or not medically necessary because they duplicate existing functionality include combination devices (e.g., combination wheeled walker and wheelchair) and battery-powered wheeled walkers when those items overlap with covered equipment. Providers should demonstrate why a new device is required and why existing equipment is inadequate.

Denials are likely when documentation does not substantiate a unique medical need, when the requested device would serve primarily as a convenience or leisure item, or when the request fails to meet the DME criteria in the member's plan.

Durable medical equipment is not medically necessary when the policy's medical necessity criteria are not all met. That includes situations without a documented physical functional impairment related to ADLs, absent a clinical assessment and rationale in the medical record, lack of a prescribing practitioner order, or when the item does not meet the definition of DME.

Examples of items routinely considered not medically necessary include accessory add-ons/upgrades when a basic DME item meets needs, deluxe equipment when standard equipment suffices, elastic garments such as SPIO, athletic/exercise equipment (e.g., treadmills, stationary bikes, ROMTech), comfort/convenience items, and any DME dispensed without a prescription or used primarily for nonmedical purposes.

Devices that manipulate or alter auditory feedback (Altered Auditory Feedback, AAF; e.g., delayed or frequency-shifted auditory feedback) intended for treatment of stuttering are considered investigational given insufficient evidence of effectiveness and are therefore not supported as medically necessary.

AAF/stuttering devices are listed among items considered non-covered or investigational; requests for these devices should be denied when submitted as DME for treatment of stuttering or dysfluency because the evidence does not establish therapeutic benefit.

Medical necessity rules and tests

DME medical necessity — DME covered when ALL criteria are met

DME covered when ALL criteria are met (see coverage criteria).

DME need: Documented functional impairment affecting activities of daily living (ADLs) that can be addressed by the DME; Clinical assessment and rationale documented in the medical record (including face-to-face evaluation when required) supporting the specific item requested; The DME is prescribed by a qualified health care practitioner; The item meets the definition of DME (appropriate for home use, durable, non-implantable, primarily medical in purpose); The item is not investigational or unsafe and is not excluded by plan benefits or contractual exclusions; When applicable, documentation of trial and failure or contraindication of less complex assistive devices (e.g., cane, walker, manual wheelchair) is provided; When applicable, documentation supports that the individual's condition requires DME for long-term use (typically 6–12 months).

All conditions required

General DME necessity considerations — Medicare contractor considerations and reasonable & necessary test

Medicare contractor considerations and general DME medical necessity test

Medicare DME coverage test: Consider whether the item fits DME categories and is appropriate for home use; whether the item has been approved for marketing by the Food and Drug Administration (FDA) and is otherwise generally considered safe and effective for the intended purpose; and whether the item is reasonable and necessary for the individual patient. For items not fitting generic categories, Medicare regional contractors (DMERC) have authority and responsibility to decide coverage based on medical consultant advice and applicable CMS guidance (e.g., Medicare Claims Processing Manual, Chapter 20).

Medicare guidance for DME coverage decisions

Codes, coding updates, and duration expectations

HCPCS codes mentionedHCPCS

E0150	Combination wheeled walker with seat and transport chair, folding, adjustable or fixed height (e.g. Rollz Motion rollator walker and wheelchair) (new code effective 10/01/25)
E0152	Walker, battery powered, wheeled, folding, adjustable or fixed height
E1399	Durable medical equipment, miscellaneous

Coding updates referenced in policy historyHCPCS

E1399	Added (general HCPCS unspecified DME code) as noted in policy history
E0152	Added HCPCS code (moved from policy 10.01.533)
E0150	Corrected HCPCS code (was E1050, corrected to E0150)

inv-09: Long-term use duration — expected duration 6-12 months

Expected long-term use6–12 months (item is considered long-term when need is typically 6–12 months or more)

Documentation requiredMedical record must document the individual's expected duration of need when long-term use applies

Relation to ADL impairmentLong-term need should be tied to documented physical functional impairment affecting ADLs

inv-10: Medicare reasonable and necessary test — device must be FDA-approved, safe/effective, reasonable and necessary

FDA marketing approvalItem should have been approved for marketing by the Food and Drug Administration (FDA)

Safety and effectivenessItem should be generally considered safe and effective for the intended purpose

Reasonable and necessaryItem must be reasonable and necessary for the individual patient per Medicare contractor determination

What providers and suppliers must do

Prior Authorization

Prior Authorization Required

Prior authorization is required when the member's plan requires review for the requested DME item. Providers should verify prior authorization requirements before ordering or dispensing DME.

Verify prior authorization rules with the member's plan prior to claim submission.
If prior authorization is required, include all supporting documentation listed in the Documentation callout.
Affected HCPCS: E0150 (Combination wheeled walker and wheelchair — new code effective 10/01/25), E0152 (Battery powered walker), E1399 (DME, miscellaneous).

Billing Rule

Coding and Prior Authorization Impact

Updates to coding can change which services require prior authorization and how claims are adjudicated. New/changed codes (for example E0150 effective 10/01/25, E0152, and E1399) should be used on claims and may trigger prior authorization or medical review.

Use the current HCPCS code effective dates when submitting claims.
E1399 may require additional documentation to justify use of an unlisted/miscellaneous DME code.
Correct coding of E0150 (combination wheeled walker and wheelchair) is important to avoid inappropriate coverage determinations.

Denial Risk

Denial Triggers for DME Requests

Denials commonly occur when required clinical information is missing or the request does not meet medical necessity criteria. Requests are at risk of denial if the documentation does not show the DME is necessary to meet basic activities of daily living or if the item duplicates existing equipment.

Missing or incomplete face-to-face clinical assessment or order/prescription.
No documentation of current functional impairment or how the DME will address basic ADLs.
Request is for duplicate or redundant equipment that meets the same functional need.
Requested item is primarily for convenience, leisure, or recreational use, or is considered experimental/investigational.

Denial Risk

Not Medically Necessary / Denial Conditions

The plan may consider a request not medically necessary when the device does not meet the definition of DME, is not primarily to meet basic ADLs, or when the device duplicates existing equipment. Examples include luxury upgrades, convenience items, and equipment used primarily for recreational activities.

Accessory add-ons or deluxe upgrades when standard equipment meets functional needs.
Equipment used primarily for leisure/recreational activities (e.g., specialty wheelchair wheels for sports).
Redundant or back-up DME not used as the primary device to meet functional needs.

Documentation Required

Required Documentation for Medical Necessity

Provide complete documentation to support medical necessity with the initial prior authorization request and on claim submission. Incomplete documentation is a frequent reason for denial.

Face-to-face clinical evaluation by a physician or qualified professional with documentation in the medical record.
An order/prescription that states the therapeutic purpose of the DME and the provider responsible for the individual's care.
Detailed description of the individual's physical functional impairment and how it limits ADLs without the DME.
Duration of need (e.g., expected long-term use typically 6–12 months or more, when applicable).
Documentation of conservative measures tried and clinical rationale if those were inadequate (see Trial of Conservative Devices).

Note

Member Benefit and Documentation Guidance

Consult the member's benefit booklet or contact customer service to confirm coverage limits, rental vs. purchase rules, and any plan-specific requirements. Benefit differences may change whether an item is covered even if medically necessary.

Confirm rental vs. purchase cost comparisons and plan limits before ordering.
Contact member services for questions about benefit exclusions or quantity limits.
Include plan-specific authorization numbers and benefit verification information with claims when applicable.

Documentation Required

Trial of Conservative Devices

Document trials of less complex or conservative assistive devices and explain why they were inadequate, unsafe, or contraindicated prior to approving more complex DME.

List prior assistive devices tried (e.g., cane, standard walker, manual wheelchair) and dates of trial.
Describe objective reasons the conservative device did not meet functional needs (e.g., unsafe, contraindicated, insufficient support).
If trials were not possible, provide clinical justification why (e.g., contraindication or acute limitation).

Note

Provider Action Summary

Always include operational and clinical details to support medical necessity and billing: correct HCPCS coding, documentation of function and ADLs, prior authorization when required, and benefit verification.

Ensure HCPCS/CPT codes used match the product and effective code dates.
Attach clinical notes, face-to-face evaluation, and the prescribing order to the prior authorization or claim.
When using miscellaneous/unlisted codes (e.g., E1399), attach itemized description, justification, and manufacturer information as applicable.

Rule	Policy guidance
Rental vs purchase decision
Purchased equipment may be allowed when purchase is less expensive than rental or when the item is not available for rental; rental charges may be covered when rental is less expensive than purchase.

When policy is silent	What to do / guidance
Specific rental versus purchase rules not specified in this policy section
Refer to the member benefit booklet or contact member services to determine plan-specific rental versus purchase limits and apply CMS guidance as applicable; this policy is a guide and coverage is subject to member contract terms.

Items considered investigational or not covered

The policy lists a range of specific items that are non-covered or considered investigational. Notable examples include athletic/exercise equipment (treadmills, stationary bikes, ROMTech), altered auditory feedback (AAF) devices for stuttering, and the combination wheeled walker and wheelchair (E0150).

Other explicitly non-covered items include equipment primarily for environmental control or comfort (air conditioners, humidifiers, furniture), first-aid/precautionary devices (e.g., AEDs), home or vehicle modifications, institutional-only equipment, maintenance/service fees, and multiple-function consumer hardware that is not primarily medical.

The policy also calls out specific investigational or non-covered items added in history notes: remote hand-held IOP monitors (e.g., iCare HOME2) (E1399) and battery-powered wheeled walkers (E0152). Stabilizing Pressure Input Orthoses (SPIO) are also noted as lacking sufficient evidence to support effectiveness and are treated as non-covered.

Remote hand-held intraocular pressure (IOP) monitors such as the iCare HOME2 are classified as investigational and non-covered; the policy indicates these devices are billed using an unspecified DME code (e.g., E1399) and are not supported as DME.

Altered auditory feedback (AAF) and other stuttering devices are likewise considered unsupported by the evidence and treated as non-covered or investigational for treatment of stuttering or dysfluency. Battery-powered wheeled walkers (E0152) are also listed among items described as not covered in the policy history.

Providers should refer to the member's benefit booklet and related policies for plan-specific coverage determinations, but these items are explicitly called out as not covered in the guideline.

Key definitions used in this policy

inv-20: ADLs — activities of daily living definitions

AmbulatingWalking; mobility for movement within the home or elsewhere

Bathing/DressingPersonal hygiene tasks including bathing and putting on clothing

EatingAbility to feed oneself or partake in meals

Hygiene/GroomingPersonal care activities such as toileting hygiene, grooming, and oral care

ToiletingAbility to get to and use the toilet independently or with assistive devices

TransferringMoving between surfaces (e.g., bed to chair) necessary for daily function

inv-21: Mobility limitation — definition related to mobility-related ADLs and risk

DefinitionA mobility limitation is a limitation that prevents accomplishing mobility-related ADLs entirely, places the person at increased risk of morbidity/mortality when attempting the activity, or prevents completion within a reasonable time frame

Clinical relevanceUsed to determine whether DME is necessary to meet mobility-related ADLs

Distinction from other impairmentsPhysical functional impairment excludes social, emotional, and psychological impairments

inv-22: Durable medical equipment (DME) — definition: home-use, durable, non-implantable, prescribed by provider

Place of useItems appropriate for and primarily used in the home setting

DurabilityDesigned to be long-lasting and able to stand repeated use (durable)

Non-implantable and reusableNot implantable in the body and reusable (non-disposable)

Medical purpose and prescriptionOrdered or prescribed by a physician or qualified provider and primarily used to serve a medical purpose

Not for convenienceNot solely for the convenience of the patient or caregiver and not useful to a person without illness or injury

inv-23: Altered auditory feedback (AAF) — device definition and insufficient evidence statement

DefinitionA device that manipulates or alters auditory feedback (delayed auditory feedback or frequency-shifted auditory feedback) used to help with speech dysfluency or stuttering

Alternate namesAlso referred to as delayed auditory feedback (DAF) or frequency-shifted auditory feedback (FAF)

Evidence statementThere is insufficient evidence currently to conclude that stuttering/AAF devices are effective for treatment of stuttering or dysfluency; therefore they are considered not supported by evidence for coverage

OpenPayer

Durable Medical Equipment (DME) coverage

Coverage criteria and exclusions

Medical necessity rules and tests

Codes, coding updates, and duration expectations

What providers and suppliers must do

Required supporting documentation

Rental vs purchase guidance

Items considered investigational or not covered

Key definitions used in this policy

Policy background and scope

Replacement and repair guidance

See documentation requirements