Currentpriority healthPolicy N/A

Miscellaneous Durable Medical Equipment (DME) Supplies

Defines payment, billing, documentation, and quantity limits for miscellaneous DME supplies for Priority Health members; applies to commercial, Medicare (follows CMS), and Medicaid (follows MDHHS).

Policy Summary

Payerpriority health

PolicyMiscellaneous Durable Medical Equipment (DME) Supplies

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 25, 2025

Next Review DateN/A

Key ActionFor Medicare indications not meeting NCD/LCD or medical policy criteria, submit a Pre‑Service Organization Determination (PSOD).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8/moA4244 limit

10/moA4330 limit

240/moA4450 limit

1/yr (10/yr RR)E0275 limit

Medicare/MedicaidProgram applicability

Coverage, Billing and Documentation Rules

Policy Summary

Payerpriority health

PolicyMiscellaneous Durable Medical Equipment (DME) Supplies

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 25, 2025

Next Review DateN/A

Key ActionFor Medicare indications not meeting NCD/LCD or medical policy criteria, submit a Pre‑Service Organization Determination (PSOD).

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

HCPCS Codes, Modifiers, and Quantity Limits

Required HCPCS Modifiers for Wheelchair DMEHCPCSCovered

KX	Indicates policy criteria met for wheelchair DME items; required or claims will deny
GA\|GY\|GZ	Per CMS LCDs one of these modifiers is required for processing wheelchair DME items

Listed HCPCS supply frequency limitsHCPCSCovered

A4244	Frequency limit = 8 Per Month
A4245	Frequency limit = 2 Per Month
A4246	Frequency limit = 8 Per Month
A4330	1 = 10 Per Month
A4450	1 = 240 Per Month
E0275	1 = 1 Per Year; 10 Per Year with Modifier RR

Usual maximum quantities

A42448 per month

A42452 per month

A42468 per month

A433010 per month

A4450240 per month

E02751 per year; 10 per year with modifier RR

Prior Authorization and Authorization Notes

Prior Authorization

Obtain PSOD for Medicare indications not covered by NCD/LCD/policy

For Medicare indications that do not meet the criteria of an NCD, local LCD, or a specific medical policy you must obtain a Pre-Service Organization Determination (PSOD) prior to providing the item or service. See the Provider Manual for PSOD submission details.

Denial Risk

Authorizations do not guarantee payment; follow coding/billing/documentation

An authorization does not guarantee payment — correct coding, billing, and complete documentation consistent with Priority Health and applicable coding guidelines must still be met. Failure to follow billing/coding or document the service may result in claim denial, recoupment, or other payment recovery actions.

Authorizations do not supersede coding, billing or reimbursement requirements.
Services and items must be performed and fully documented in the medical record to the highest level of specificity.
Priority Health may reject or deny claims, or recover payments, if guidelines and contractual requirements are not followed.

Policy Definitions and Terms

DME supplies (policy definition)

Policy definitionPayment and documentation requirements associated with various durable medical equipment (DME) supplies.

Capped rental billingCapped rental devices must be billed with a 'from' and 'to' date span that encompasses the month being billed; overlapping dates of service will be denied.

Laterality and bilateral reimbursementTo receive separate reimbursement for bilateral items, submit RT and LT modifiers on separate lines; up to one unit per side with a maximum of two rental rates in the same calendar month.

Supply date-span billingSupplies billed for a date span must follow the same 'from'/'to' date guidelines as capped rentals to ensure accurate claim processing.

Calendar Month

DefinitionA Calendar Month is the period from a day of one month to the corresponding day of the next month.

Billing implicationDate spans for capped rentals should encompass the calendar month being billed to allow accurate processing.

Overlap ruleClaims with overlapping dates of service will result in denial.