Preauthorization thresholds

Prior authorization is required for DME purchases or rentals that exceed $1,000.00 for commercial members and $500.00 for Medicaid/Healthy Michigan Plan members; failure to obtain required preauthorization may result in claim denial.

• Thresholds: > $1,000 (commercial); > $500 (Medicaid/HMP)

Refer to related billing/coding policies

Refer to the Priority Health billing and device-specific policies listed in the policy for detailed coding, modifier and prior authorization procedures before submitting claims.

• See DME Capped Rental No. 110; Modifiers No. 060; Place of Service No. 050; Repair & Replacement No. 108; Compression Garments No. 067; Negative Pressure Wound Therapy Pumps No. 072

Pre-authorization requirements

Certain equipment and supplies require pre-authorization; Home Infusion providers must obtain prior authorization for all service lines per the policy cross-reference.

• Equipment and supplies listed under 'Equipment and supplies requiring pre-authorizations' require PA
• All service lines for Home Infusion providers require prior authorization (see Parenteral Nutritional Therapy No. 91517)

Enteral feedings pre-auth reference

Enteral feedings and related supplies use a separate policy for prior authorization and coding details; providers should submit PA requests referencing Policy No. 91278.

• See medical policy Enteral Nutritional Therapy No. 91278 for authorization/coding guidance

Infusion pumps pre-auth reference

Infusion pumps (implantable and external) are governed by a separate Infusion Services and Equipment policy; obtain prior authorization per Policy No. 91414 when applicable.

• See Infusion Services and Equipment No. 91414 for authorization rules
• Home Infusion service lines require PA (see Parenteral Nutritional Therapy)

PA required by HCPCS code

Prior authorization requests must reference the specific HCPCS code for the intermittent pneumatic compression appliance or replacement sleeve corresponding to the device and anatomic site.

• Examples: E0656–E0660, E0665–E0673 etc. — PA must reference the exact HCPCS code

HCPCS codes listed (no PA statement in chunks)

The policy enumerates HCPCS codes for pneumatic compression appliances and replacement sleeves; providers must use the correct HCPCS when submitting claims and PAs.

• See listed HCPCS ranges (e.g., E0656–E0673) for device and sleeve mappings

Billing / coding requirements

Bill with the precise HCPCS code that corresponds to the device or replacement sleeve; when an unlisted code is used, include explanatory notes on the claim.

• Correct HCPCS examples: E0660, E0665–E0676
• Unlisted device claims (e.g., E0677) require explanatory notes

Prior authorization / claim documentation - compression appliances

Claims for intermittent limb compression devices, nonpneumatic sequential compression garments, and replacement sleeves must include required documentation; unlisted-code claims need explanatory notes to support adjudication.

• Explanatory notes required for unlisted intermittent limb compression device codes (E0676/E0677 context)
• Include device description, anatomic site, and justification with PA/claim

Bilirubin Light (PA after 7 days rental)

E0202 (phototherapy bilirubin light) requires prior authorization after seven days of rental; submit PA if rental extends beyond 7 days.

• Code: E0202 — PA required after 7 days rental

Pulse Oximeter (PA after 3 months)

Pulse oximeter rentals require prior authorization after three months of rental; lack of prior authorization after that threshold can result in claim denial.

• Pulse oximeter rental threshold: 3 months before PA required

TENS Devices (rental PA rules)

TENS device rental authorization rules: Medicare requires prior authorization from the start of rental; for Medicaid and Commercial plans, authorization is required after 2 months of rental for diagnoses not listed as exempt.

• Medicaid/Commercial: specified ICD-10 diagnoses are exempt; all other diagnoses require PA after 2 months rental
• Medicare: PA required from start of rental period

Prior authorization required — use InterQual

When prior authorization is required, providers must use InterQual criteria via Priority Health Prism for authorization decisions and include supporting medical necessity documentation in the PA request.

• Access InterQual: Priority Health Prism → Authorizations → Authorization Criteria Lookup
• Submit documentation showing InterQual criteria are met

Not medically necessary coding

A7523 (tracheostomy shower protector) was added to the not medically necessary coding section and should not be authorized as DME absent an approved individual case review.

• A7523 listed as Not Medically Necessary in coding list
• Coverage exceptions require individual case review with prior plan approval

Pneumatic compression device step requirement

Requests for calibrated gradient-pressure pneumatic compression devices must document prior failure of non‑calibrated gradient pressure devices before calibrated devices will be approved.

• Documentation must show non‑calibrated device trial and failure before calibrated device approval

Conservative-first expectation for PCDs

Conservative/stepwise measures (e.g., compression garments, complex decongestive therapy) are expected before pneumatic compression device use; document prior conservative therapy in the PA.

• ISL 2023 and International Lymphoedema Framework endorse conservative-first management for lymphedema
• Document prior use of compression garments and CDT before requesting PCDs

Capped Rental - Authorization Required

Capped rental items require authorization per the capped rental policy header; follow capped-rental modifier rules when billing rental months.

• Capped rental authorization required
• Use KH/KI/KJ modifiers appropriately for initial and subsequent rental months

Repair and compliance documentation

Include an itemized invoice with repair claims and be prepared to document compliance or device trial results when requesting continued coverage or replacement.

• Claims for repairs should include an itemized invoice
• Documentation of compliance or device trials may be required for continued authorization or replacement decisions

Capped rental modifier documentation

Use capped-rental modifiers KH, KI, and KJ correctly on initial and monthly rental claims to reflect the capped rental timeline and avoid rental-payment denials.

• KH — initial claim/first month; KI — second/third month; KJ — months 4 to final capped rental month

Compression appliance claim notes

Explanatory notes must accompany claims billed with miscellaneous DME supply/accessory code A9900 and when billing compression-sleeve or other accessory entries to justify the item.

• A9900 (miscellaneous DME supply/accessory) requires explanatory notes on the claim
• Provide description tying A9900 to the primary HCPCS and clinical justification

Document anatomic location with HCPCS

When billing replacement sleeves, report the sleeve using the specific HCPCS code that corresponds to the anatomic location or sleeve type (trunk, chest, full leg, full arm, half leg, half arm) as listed in the HCPCS tables.

• Map sleeve to exact HCPCS (e.g., E0656 trunk, E0660 full leg, E0665 full arm, E0666 half leg)

Explanatory notes for unlisted codes

Claims billed with unlisted HCPCS codes (e.g., intermittent limb compression device not otherwise specified) must include explanatory notes; absence of these notes may trigger denial or additional documentation requests.

• Unlisted codes such as E0676/E0677 require explanatory notes describing the item and justification
• Include PA/clinical rationale when submitting unlisted-code claims

Explanatory notes for unlisted codes

Explanatory notes must also accompany claims billed with unlisted power vehicle (K0812) or other unlisted K-codes to describe the device and clinical need.

• K0812 (power vehicle not otherwise classified) — include explanatory notes with claim

Bilirubin Light (PA after 7 days rental)

Phototherapy bilirubin light (E0202) rentals beyond seven days require prior authorization; include rental duration in documentation.

• E0202 — PA required after 7 days rental; document rental start date and clinical indication

Medical necessity documentation and individual case review

When prior authorization is required, submit documentation demonstrating medical necessity; individual case review may allow exceptions for investigational items with prior plan approval.

• Provide InterQual-supported criteria and supporting clinical records in the PA
• Individual case review requests require prior plan approval and will be decided by medical director/clinical pharmacist

Coding and billing references

Check coding and billing references added to the policy; A7523 was added to the Not Medically Necessary list and should not be authorized without an approved exception.

• Review coding updates in the policy's coding section prior to submission
• A7523 now appears as Not Medically Necessary

Preauthorization requirement

Failure to obtain required preauthorization for DME above the stated thresholds (> $1,000 commercial; > $500 Medicaid/HMP) may result in denial of payment.

• Denial risk tied to exceeding PA thresholds without authorization

CPM routine-use denial risk

Routine requests for CPM devices after knee or shoulder surgery submitted as standard postoperative rehabilitation may be denied because evidence and society guidance do not support routine CPM use.

• CPM not supported for routine TKA or shoulder postoperative rehab
• Submit individualized justification and expect denial for routine use

Wheelchair modifier denial risk

Claims for wheelchair DME items reported without the KX modifier will deny as non-payable per policy; for Medicare, KX/GA/GY/GZ modifier guidance per LCDs also applies.

• Append KX to indicate policy criteria met; Medicare may require KX, GA, GY, or GZ

Laterality modifier denial risk

Omiting laterality modifiers (RT, LT) for bilateral accessories can result in claim denial; include RT or LT on claims when supplying side‑specific items.

• Use RT/LT modifiers to identify right or left side when billing bilateral accessories

Coding-dependent denial risk

Claims may be denied if billed without the appropriate HCPCS code corresponding to the device or replacement sleeve; ensure coding matches the device/anatomic site to avoid denial.

• Examples of codes that must match device: E0656–E0660, E0665–E0673

Unlisted-code documentation risk

Claims billed with unlisted HCPCS codes must be accompanied by explanatory notes; failure to include required explanatory notes may trigger denial or request for additional documentation.

• Unlisted intermittent limb compression device codes require explanatory notes (E0676/E0677 context)
• Provide device description, clinical rationale, and cost when using unlisted codes

Unlisted code documentation requirement

Claims using unlisted HCPCS codes require explanatory notes describing the item and justification; absence of notes may lead to denial or additional review.

• Explanatory notes must accompany unlisted compression appliance codes and related claims

Negative Pressure Wound Therapy notes

A9272 is listed as Not Medically Necessary; A7000 (disposable canister) is noted as no prior authorization required — expect denials for A9272 and no PA needed for A7000.

• A9272 — Not medically necessary (claim denial risk)
• A7000 — No prior authorization required

Pulse Oximeter (rental authorization)

Pulse oximeter rentals require prior authorization after three months; failure to obtain PA after that period can trigger claim denial.

• PA threshold: 3 months rental before PA required