Priority Health DME Coverage & Prior Auth Update

Coverage criteria and device-specific guidance

General Coverage and Device-Specific Criteria

DME is medically necessary when applicable InterQual criteria are met and policy restrictions apply. Coverage decisions favor the least costly effective equipment and are subject to Health Management Department discretion.

General DME Medical Necessity: Equipment must meet applicable InterQual criteria; be primarily for a medical purpose, appropriate for home use, and not useful absent illness/injury/disease; if quality and effectiveness are comparable, the least costly equipment will be covered; the decision to purchase or rent DME and related supplies/accessories is at the discretion of the Health Management Department.

See InterQual criteria for device-specific clinical requirements.

Repair and Replacement: Repairs and maintenance resulting from normal use are covered; repairs due to misuse/abuse, lost or stolen equipment are not covered. For repairs greater than 60% of the cost of new, replacement will be at Priority Health's discretion. Replacement is covered if equipment is past the useful lifetime (useful lifetime considered to be no less than 5 years) or required due to body growth.repair >60% of new cost; useful lifetime >= 5 years

Claims for repairs should include an itemized invoice.

Capped Rental and Ownership: Capped rental period is 10 months; ownership transfers to the beneficiary after the capped rental period is complete. Loaner equipment is covered for member‑owned equipment outside the capped rental period; payment will not be made for rental of supplier‑owned equipment within the 10‑month capped rental period. When a member changes carriers during a capped rental period, Priority Health will allow coverage for the number of months remaining up to the 10‑month cap.10 months

Amount paid during capped rental may be applied toward an upgraded item during the capped rental period.

Preauthorization and Compliance: Preauthorization is required for DME with cost greater than $1,000 for commercial members and greater than $500 for Medicaid/Healthy Michigan Plan members. Member compliance with use of equipment may be reviewed and can affect continued authorization and coverage.>$1,000 commercial; >$500 Medicaid/HMP

Examples of compliance‑monitored devices include secretion clearance devices and electrical stimulators.

Device Trials and Documentation: Certain devices require documented trials and evidence of benefit prior to continued authorization or upgraded devices. Examples: secretion clearance devices require a 4–6 week device trial with daily use and documentation of increased sputum production; electrical stimulators (e.g., NMES) require review of a compliance log for authorization beyond a 2‑month initial trial.4-6 weeks for secretion clearance devices; 2 months for initial NMES trial

Requests for calibrated gradient pressure pneumatic compression devices require documentation of failure with non‑calibrated devices.

Pneumatic Compression Devices: Segmental or non‑segmental pneumatic compression devices (calibrated or non‑calibrated gradient pressure) in the home setting are medically necessary when InterQual criteria are met; they are not medically necessary in the home for active cellulitis, ischemic vascular disease, lymphedema limited to head/neck/trunk/chest/abdomen, prevention of DVT in the home, or severe peripheral neuropathy. Because evidence does not show superiority of calibrated devices, the least costly equipment will be covered; calibrated devices require prior failure with non‑calibrated devices.

Non‑pneumatic compression devices are not medically necessary due to insufficient evidence.

Continuous Passive Motion (CPM) Coverage

Continuous passive motion (CPM) devices are a covered benefit only for specified immediate post-operative indications and subject to duration limits.

CPM Coverage: CPMs are covered in the immediate post‑operative rehabilitation period following rotator cuff repair or total knee replacement; coverage is limited to 21 days; applies to HCPCS codes E0935–E0936. CPMs are not a covered benefit for any other anatomic location or indication (for example, hip or ankle).21 days

Applies only to the specified post‑operative conditions.

The policy excludes routine upgrades and extras that are not medically necessary. Deluxe equipment, duplicate or backup equipment (for example, multiple wheelchairs for different settings) and first-aid or precautionary equipment such as standby portable oxygen are not covered. Maintenance and service fees for capped-rental items are excluded. Personal or household items, including comfort or convenience items, household fixtures or home modifications (e.g., bath bars, ramps), furnishings (lift chairs, whirlpools, safety beds), and self-help or adaptive aids are not a covered benefit.

Certain device types and examples are explicitly excluded. E0675 (pneumatic compression device for arterial insufficiency) is listed as Not Covered for any plan. Wound suction supplies such as A9272 (wound suction, disposable) are marked Not Covered. The policy also lists negative-pressure wound therapy pumps and related canisters among device types addressed in the coding and exclusions sections.

The policy enumerates specific HCPCS/K codes that are not covered and will be treated as excluded when billed. Examples from the Not Covered list include E0190 (positioning cushion/pillow/wedge), K1036 and K1037 (supplies/accessories and docking station), and items such as E0152, E0201, E0469, E0715, E1022, E1023, E1831, and E1832. Providers should not expect payment for these codes under this policy.

Multiple wheelchair and hospital bed variants are identified as not covered for Medicaid and/or Medicare in the policy. Several hospital bed codes (for example, various total electric and institutional bed codes) and many manual and power wheelchair variants are marked Not Covered for Medicaid or Medicare. Providers should consult the specific code entries to determine which bed and wheelchair configurations are excluded for those product lines.

The policy lists a set of HCPCS and K-codes under the heading Non-Covered. These include (but are not limited to) K1036, K1037, E0152, E0201, E0469, E0715, E1022, E1023, E1831, and E1832. These codes are explicitly identified as not covered by the policy for payment purposes.

Home-use pneumatic compression devices are covered only when InterQual criteria are met, and the policy sets explicit clinical exclusions. They are not medically necessary in the home for active cellulitis, ischemic vascular disease, lymphedema limited to head/neck/trunk/chest/abdomen, for prevention of deep venous thrombosis in the home setting, or for members with severe peripheral neuropathy. Additionally, calibrated gradient-pressure devices require documentation of failure with non-calibrated devices before the calibrated device will be considered.

The policy states that non-pneumatic compression devices (for example, the Koya DaySpring) are considered not medically necessary due to insufficient evidence of effectiveness in improving long-term health outcomes and therefore are not covered for home use.

Items listed in the policy’s Non-Covered section are treated as exclusions at the time of billing. When claims are submitted for codes on that list, they will be processed as non-covered/denied under this policy (for example, K1036, K1037, E0152, E0201, E0469, E0715, E1022, E1023, E1831, and E1832).

E2001 (home suction pump, portable or stationary, for use with external urine management system) is listed in the Durable Medical Equipment coding section. The excerpt does not state an explicit coverage stance for E2001, but its inclusion in the DME list indicates it is a tracked DME code that may be subject to policy-specific coverage criteria or review.

HCPCS, modifiers, and coding rules

Capped Rental modifiersModifier

KH	DMEPOS item, initial claim, first month rental
KI	DMEPOS item, second- or third-month rental
KJ	DMEPOS item, months 4 to 15 of capped rental

Wheelchair modifiersModifier

KX	Indicates policy criteria met for wheelchair DME items
GA	Medicare - Advance Beneficiary Notice-type modifier per LCD
GY	Medicare - Not covered by Medicare
GZ	Medicare - Expectation of denial
RT	Right side laterality
LT	Left side laterality

Specific HCPCS codes and item-level guidanceHCPCS

E0465	Home ventilator, any type, used with invasive interface
E0466	Home ventilator, any type, used with noninvasive interface
E0467	Home ventilator, multi-function respiratory device (Not covered for Medicaid)
A4600	Sleeve for intermittent limb compression device, replacement only, each
A9900	Miscellaneous DME supply, accessory, and/or service component
E0650	Pneumatic compressor, nonsegmental home model
E0651	Pneumatic compressor, segmental home model without calibrated gradient pressure
E0652	Pneumatic compressor, segmental home model with calibrated gradient pressure
E0655	Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm
E0656	Segmental pneumatic appliance for use with pneumatic compressor, trunk

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Speech Generating Device and initial power vehiclesHCPCS

E2500	Speech generating device, digitized speech, using prerecorded messages, less than or equal to eight minutes recording time
E2502	Speech generating device, digitized speech, using prerecorded messages, greater than eight minutes but less than or equal to 20 minutes recording time
E2504	Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time
E2506	Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time
E2508	Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device
E2510	Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access
E2511	Speech generating software program, for personal computer or personal digital assistant
E2512	Accessory for speech generating device, mounting system
E2513	Accessory for speech generating device, electromyographic sensor
E2599	Accessory for speech generating device, not otherwise classified

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Additional power vehicles and select DMEHCPCS

K0801	Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds
K0802	Power operated vehicle, group 1 very heavy-duty, patient weight capacity 451 to 600 pounds
K0806	Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds - Not Covered Medicare
K0807	Power operated vehicle, group 2 heavy-duty, patient weight capacity 301 to 450 pounds - Not Covered Medicare
K0808	Power operated vehicle, group 2 very heavy-duty, patient weight capacity 451 to 600 pounds - Not Covered Medicare
K0812	Power operated vehicle, not otherwise classified (Explanatory notes must accompany claims billed with unlisted codes.)
E0202	Phototherapy (bilirubin) light with photometer

Capped rental and hospital beds / oximeterHCPCS

E0193	Powered air flotation bed (low air loss therapy)
E0194	Air fluidized bed
E0371	Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width
E0372	Powered air overlay for mattress, standard mattress length and width
E0373	Nonpowered advanced pressure reducing mattress
E0445	Oximeter device for measuring blood oxygen levels noninvasively (Not Covered Medicare)
E0250	Hospital bed, fixed height, with any type side rails, with mattress
E0251	Hospital bed, fixed height, with any type side rails, without mattress
E0255	Hospital bed, variable height, hi-lo, with any type side rails, with mattress
E0256	Hospital bed, variable height, hi-lo, with any type side rails, without mattress

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Lifts, standers, transport chairs and related itemsHCPCS

E0170	Commode chair with integrated seat lift mechanism, electric, any type (Not Covered for Medicaid)
E0171	Commode chair with integrated seat lift mechanism, nonelectric, any type
E0172	Seat lift mechanism placed over or on top of toilet, any type (Not Covered)
E0627	Seat lift mechanism, electric, any type (Not covered for Medicaid)
E0629	Seat lift mechanism, non-electric, any type (Not covered for Medicaid)
E0630	Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s), or pad(s)
E0635	Patient lift, electric, with seat or sling
E0636	Multipositional patient support system, with integrated lift, patient accessible controls
E0637	Combination sit-to-stand frame/table system, any size including pediatric, with seat lift feature
E0638	Standing frame/table system, one position, any size including pediatric

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Manual and power wheelchair base codesHCPCS

E2298	Complex rehabilitative power wheelchair accessory, power seat elevation system, any type
K0001	Standard wheelchair
K0002	Standard hemi (low seat) wheelchair
K0003	Lightweight wheelchair
K0004	High strength, lightweight wheelchair
K0005	Ultralightweight wheelchair
K0006	Heavy-duty wheelchair
K0007	Extra heavy-duty wheelchair
K0008	Custom manual wheelchair/base (Not covered for Medicaid)
K0009	Other manual wheelchair/base (Explanatory notes must accompany claims billed with unlisted codes.)

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Additional power wheelchair group and airway clearance deviceHCPCS

K0841	Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
K0890	Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds
K0891	Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds
K0898	Power wheelchair, not otherwise classified (Explanatory notes must accompany claims billed with unlisted codes.)
E0483	High frequency chest wall oscillation air-pulse generator system (includes hoses and vest), each

Loaner/temp replacement, Not Covered items, and select suppliesHCPCSNot Covered

K0462	Temporary replacement for patient-owned equipment being repaired, any type (Not covered for Medicaid)
E0190	Positioning cushion/pillow/wedge, any shape or size, includes all components and accessories (Not Covered)
K1036	Supplies and accessories for low frequency ultrasonic diathermy treatment device, per month (Not Covered)
K1037	Docking station for use with oral device/appliance used to reduce upper airway collapsibility (Not Covered)
E0152	Walker, battery powered, wheeled, folding, adjustable or fixed height (Not Covered)
E0201	Penile contracture device, manual, greater than 3 lbs traction force (Not Covered)
E0469	Lung expansion airway clearance, continuous high frequency oscillation, and nebulization device (Not Covered)
E0715	Intravaginal device intended to strengthen pelvic floor muscles during kegel exercises (Not Covered)
E1022	Wheelchair transportation securement system, any type includes all components and accessories (Not Covered)
E1023	Wheelchair transit securement system, includes all components and accessories (Not Covered)

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Non-CoveredHCPCSNot Covered

K1036	Supplies and accessories (e.g., transducer) for low frequency ultrasonic diathermy treatment device, per month
K1037	Docking station for use with oral device/appliance used to reduce upper airway collapsibility
E0152	Walker, battery powered, wheeled, folding, adjustable or fixed height
E0201	Penile contracture device, manual, greater than 3 lbs traction force
E0469	Lung expansion airway clearance, continuous high frequency oscillation, and nebulization device
E0715	Intravaginal device intended to strengthen pelvic floor muscles during kegel exercises
E1022	Wheelchair transportation securement system, any type includes all components and accessories
E1023	Wheelchair transit securement system, includes all components and accessories
E1831	Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories
E1832	Static progressive stretch finger device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories

Durable Medical EquipmentHCPCS

E2001

Suction pump, home model, portable or stationary, electric, any type, for use with external urine management system

Preauthorization cost threshold — commercial and Medicaid thresholds

Commercial preauthorization threshold> $1,000 per DME item — preauthorization required

Medicaid / Healthy Michigan Plan threshold> $500 per DME item — preauthorization required

ScopeApplies to purchase or rental decisions as described under Priority Health DME policy

Useful lifetime for replacement — >=5 years

Provider responsibilities, prior authorization, and documentation

Prior Authorization

Prior Authorization Required for Capped Rental and Specific DME

Prior authorization is required for capped rental items and certain specific DME. Submit prior authorization before delivery when possible to avoid denials.

Preauthorization threshold: DME purchases > $1,000 require prior authorization (>$500 for Medicaid and Healthy Michigan Plan).
Capped rental items requiring authorization include specialized mattresses/sleep surfaces, PAP devices (authorization after 3 units billed within 999 days), pulse oximeters (prior authorization required after 3 months rental), and hospital/specialty beds. See listed HCPCS (E0193, E0194, E0371–E0373, E0445, E0250–E0261).
Certain high-cost items (enteral feedings/supplies, ventilators) also require preauthorization per equipment list.

Prior Authorization

Prior Authorization for Listed Non‑Covered DME

Requests for coverage of items listed as non‑covered or for codes that are routinely non‑covered require prior authorization review but are frequently denied. Providers should not assume coverage without explicit approval.

Background and scope

Durable Medical Equipment (DME) is reusable medical equipment primarily intended for use in the home to treat or manage illness, injury, or disease. Coverage is determined by clinical criteria (InterQual) and policy rules that favor the least costly effective equipment. The policy addresses medical necessity, repairs, capped rental rules, device trials and compliance, and specific exclusions so that covered items meet clinical need and appropriate documentation requirements.

Key definitions

Durable Medical Equipment (DME) definition — reusable, medical purpose, primarily home use

DurabilityCan withstand repeated use — characteristic of DME

Medical purposePrimarily used to serve a medical purpose and generally not useful in the absence of illness, injury, or disease

Intended setting (highlight)Appropriate for use in the member's home (includes dwelling, relative's home, apartment, home for the aged or other institutions)

Non-Covered — items and specific HCPCS/K codes listed under Non-Covered not covered for payment

Listed non-covered HCPCS/K codes (examples)K1036, K1037, E0152, E0201, E0469, E0715, E1022, E1023, E1831, E1832 — items listed as Non-Covered are excluded from payment

Additional non-covered entry

OpenPayer

Durable Medical Equipment (DME) Coverage Criteria

Coverage criteria and device-specific guidance

HCPCS, modifiers, and coding rules

Provider responsibilities, prior authorization, and documentation

Background and scope

Key definitions