Durable Medical Equipment (DME) Coverage Criteria
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Defines San Francisco Health Plan (SFHP) coverage, authorization, and operational rules for durable medical equipment for members across specified SFHP lines of business, including Medi-Cal and certain HMO products.
No material clinical or coverage changes in this revision.
Coverage Criteria for DME and Wheelchairs
DME and Wheelchair Coverage Criteria
Covered when criteria below are met
Applies to SFHP managed lines of business
See Authorization.documentation
SFHP generally authorizes one (1) type of wheelchair per member
Wheelchairs solely for social, educational, or vocational purposes are not authorized
The following items are excluded from SFHP DME benefits and are not covered under Medicare, Medi‑Cal, or SFHP: books or other items of a primarily educational nature; air conditioners, air filters, or heaters; food blenders; reading lamps or other lighting equipment; bicycles, tricycles, or other exercise equipment; television sets; orthopedic mattresses, recliners, rockers, seat‑lift chairs, or similar furniture items; waterbeds; household items; automobile or other motor vehicle modifications; and other items not generally used primarily for health care or regularly used by persons without a specific medical need for them.
SFHP does not authorize a wheelchair or accessories when the member already possesses a wheelchair that allows the member to accomplish their Activities of Daily Living (ADLs), except where special circumstances apply (see section F). If the member's medical or functional needs have changed, or the existing wheelchair size is no longer appropriate, the provider may submit an updated functional assessment with medical justification to support a replacement or different wheelchair.
Regulatory Citations and Codes
| 42 CFR 414.202 | Regulation defining DME; referenced for purchase/rental rules |
| 42 CFR 414.224 | Regulation referenced for customized items |
| 42 CFR 414.229 | Regulation referenced for complex rehabilitative power-driven wheelchairs |
| 42 CFR 414.232 | Regulation referenced for TENS |
Provider Actions, Prior Authorization, and Submission Requirements
Prior authorization required for specialized/custom wheelchairs
Prior authorization is required for rental of specialized/custom manual wheelchairs and accessories; contracted vendors are exempt from prior authorization for standard manual wheelchairs. SFHP also requires prior authorization for purchase of powered wheelchairs and accessories, rental of loaner powered wheelchairs, and limits authorization to one type of wheelchair per member unless exceptions apply.
- Rental of a specialized/custom manual wheelchair and accessories requires prior authorization; contracted vendors do not need prior authorizations for standard manual wheelchairs.
- Purchase of powered wheelchairs and accessories requires prior authorization.
- Rental of loaner powered wheelchairs requires prior authorization.
- SFHP generally authorizes one type of wheelchair per member (see exceptions in section F).
Follow CO-22 and CO-66 for submission and timing
Submit prior authorization requests in accordance with related SFHP authorization and prior authorization policies. See CO-22 (Authorization Requests and Decision Time Frames) and CO-66 (Prior Authorization) for submission procedures and required time frames.
- Follow CO-22 for authorization request submission and decision time frames.
- Follow CO-66 for prior authorization procedures and requirements.
TENS initial rental trial required (up to 2 months)
TENS devices must be rented initially for up to two months to determine effectiveness before a purchase authorization will be considered.
- Initial rental trial up to 2 months is required before purchase or continued rental beyond trial.
Vendor must submit coded authorization and prescription copy; expect possible DME evaluation
Ensure the DME vendor submits the authorization with the specific service code and modifier (if applicable) and includes a copy of the provider's prescription; SFHP may initiate an independent DME evaluation if medical necessity is unclear.
- DME vendor is responsible for submitting authorization to SFHP with specific service codes and modifiers.
- Include a copy of the provider's prescription with the authorization submission.
- Be prepared for SFHP-initiated independent DME evaluation if medical necessity is unclear.
Prescription and authorization must be complete and current
A valid written prescription must include prescriber name, address, and telephone number; date (within 12 months); each item itemized (custom items separately specified); the medical diagnosis for each item; and the duration of medical necessity. The DME vendor must include the specific service code and modifier and a copy of the prescription with the authorization submission.
- Prescriber full name, address, and telephone number.
- Date of prescription must be within 12 months.
- Each prescribed item must be separately specified (including custom items).
- Medical condition/diagnosis for each particular DME item.
- Duration of medical necessity (e.g., '3 months' or 'permanent').
- Vendor must submit specific service code and modifier and a copy of the prescription.
Use DHCS, CMS, and Medi‑Cal guidance for supporting documentation
Follow DHCS, CMS, and Medi‑Cal guidance referenced in the policy for required supporting documentation for wheelchairs and other DME (for example, DHCS MMCD APL 15-018, Medicare Benefit Policy Manual, and Medi‑Cal DME billing guidance).
- Refer to DHCS MMCD APL 15-018: Criteria for Coverage of Wheelchairs and Applicable Seating and Positioning Components.
- Follow the Medicare Benefit Policy Manual and Medi‑Cal Durable Medical Equipment billing guidance for documentation and billing rules.
Independent DME evaluation can lead to denial
SFHP may order an independent DME evaluation; if that evaluation does not support the original prescription, the request may be denied after review by the Chief Medical Officer, Medical Director, or physician designee.
- Independent DME evaluation results that do not support the provider's prescription can trigger review and denial.
- If denied, SFHP issues a UM Decision Letter and includes the DME evaluation so the provider can request an alternate item or file an appeal.
Link requests to CO-22 and CO-66 requirements to avoid denial
Noncompliance with related authorization/prior authorization policies (CO-22 and CO-66) may result in denial of the request; ensure requests are submitted per those policies and include required documentation and timing.
- Submit requests according to CO-22 and CO-66 requirements to avoid denial.
- Include required documentation, correct codes/modifiers, and a current prescription to meet authorization linkage requirements.
Background
Durable Medical Equipment (DME) is equipment that withstands repeated use, serves a medical purpose, is not generally useful to a person in the absence of illness or injury, and is appropriate for use in or out of the home. For Medi‑Cal members under 21 years old, EPSDT standards may allow coverage to correct or ameliorate conditions even when adult Medicaid would not otherwise cover the item.
Key Definitions
Medical Necessity Criteria
Wheelchair medical necessity
Wheelchair-specific medical necessity
See policy for exceptions (e.g., inpatient SNF/ICF-DD with unusual needs)
Provider must document medical justification
Rental and Purchase Rules for DME
| Equipment / Item | Rental vs Purchase Rule | Notes / Source |
|---|---|---|
| General DME items | ||
| Rental or purchase at plan discretion; under Medi‑Cal/Healthy Workers follow Title 22 §51321/51521; rental charges that equal the purchase price convert to purchase (no further reimbursement unless repair/maintenance separately authorized) | ||
| Per Medicare discretion and Medi‑Cal Provider Manual; see Title 22 and Medi‑Cal rental month rate sheets |
| Equipment / Item | Initial Requirement | Subsequent Purchase Option / Rule |
|---|---|---|
| Transcutaneous electrical nerve stimulator (TENS) | ||
| Must initially be rented for up to 2 months to determine effectiveness | ||
| After the trial rental period, device may be purchased or continued on rental per regulations (42 USC §1834(a)(10)(C); 42 CFR 414.232(b)) |
Documentation and Billing Requirements
Provide complete prescription and coding with authorization request
The prescribing provider and DME vendor must supply a complete, valid written prescription and correct coding when requesting authorization: prescriber contact, date within 12 months, itemized equipment, diagnosis for each item, and stated duration of medical necessity; vendor must include service codes/modifiers and a copy of the prescription.
- Prescriber contact information and prescription date (≤12 months).
- Separate specification for multiple or custom items.
- Medical diagnosis per item and duration of necessity.
- Vendor submission must include the specific service code and modifier and copy of the prescription.
Use DHCS APL 15-018 and Medi‑Cal billing guidance for wheelchair documentation
Refer to DHCS MMCD APL 15-018 and Medi‑Cal DME billing guidance for required documentation supporting wheelchairs and seating/positioning components.
- DHCS MMCD APL 15-018 is cited in the policy references as the primary APL for wheelchairs and seating components.
- Also reference Medi-Cal Provider Bulletins and the Medicare Benefit Policy Manual as listed in policy references.
Non‑Covered Items
Non‑covered items include: educational materials (e.g., books); environmental appliances such as air conditioners, air filters, or heaters; food blenders; reading lamps or other lighting equipment; exercise equipment including bicycles and tricycles; television sets; furniture‑type items such as orthopedic mattresses, recliners, rockers, and seat‑lift chairs; waterbeds; general household items; automobile or other vehicle modifications; and other items not primarily used for health care or regularly used by persons without a specific medical need.
Revision History & References
Policy revision recorded (see revision history listing).
Policy revision recorded (see revision history listing).
Policy revision recorded (see revision history listing).
Original policy effective date listed in revision history (July 2011).
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