CurrentUnitedHealthcarePolicy CSO32IN.06

Durable Medical Equipment; Orthotics, Medical Supplies, and Repairs/Replacements (for Indiana Only)

State-specific UnitedHealthcare medical policy (Indiana only) governing medical necessity determinations and coverage rationale for durable medical equipment (DME), orthotics, medical supplies, repairs/replacements, ventilators, and respiratory assist devices. The policy directs use of InterQual criteria and Indiana Health Coverage Programs Provider Reference Module for specific device categories.

Policy Summary

PayerUnitedHealthcare

PolicyDurable Medical Equipment; Orthotics, Medical Supplies, and Repairs/Replacements (for Indiana Only)

Policy CodePolicy CSO32IN.06

Change TypeRevisions and removals to ventilator and InterQual references

Effective DateFeb 1, 2025

Next Review Date

Key ActionWhen determining DME medical necessity, apply the listed hierarchy of federal/state/contractual requirements and InterQual criteria; refer to the Indiana Health Coverage Programs Provider Reference Module or InterQual criteria for BIPAP and ventilators as directed.

POLICY UPDATE CHANGES

Coverage rationale language updated and references to InterQual guidance replaced/clarified (InterQual Medicare reference replaced with InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD).

Removed previous coverage statements that ventilators are covered for neuromuscular, thoracic restrictive diseases, and COPD-related chronic respiratory failure.

Removed statements declaring ventilators not covered when used only to deliver CPAP or when used in bi-level PAP mode (HCPCS E0470/E0471).

Mechanical ventilators section revised; removed prior coverage statement and updated referral instruction to InterQual CP criteria with fallback to InterQual Medicare NCD.

Clinical Evidence section removed.

Coverage Summary & Scope

This is a state-specific (Indiana) UnitedHealthcare coverage criteria policy for Durable Medical Equipment; Orthotics, Medical Supplies, and Repairs/Replacements (Policy CSO32IN.06). Coverage stance is mixed. The policy is CURRENT and applies only in the State of Indiana. It directs that when determining medical necessity clinical guidelines are applied in a specific order and primary clinical references include InterQual and the Indiana Health Coverage Programs Provider Reference Module. Effective date: 2025-02-01; Last review: 2025-02-01.

Medical Necessity Determination Criteria

General Medical Necessity Determination

When determining medical necessity, clinical guidelines will be applied in the following order:

Order of references: Federal, state, and contractual requirements are applied
InterQual CP: Durable Medical Equipment
InterQual Medicare fallback: InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD
CMS DME MAC: Centers for Medicare & Medicaid Services (CMS) DME Medicare Administrative Contractor (MAC)
UHC Community Plan Policy: UnitedHealthcare Community Plan Medical Policy

Ventilators and Respiratory Assist Devices (age 2 years and older)

Applies to patients age 2 years and older. For mechanical ventilators, use InterQual CP Home Mechanical Ventilation Devices; if medical necessity cannot be determined with InterQual CP, refer to InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD.

Primary criteria: Apply InterQual CP: Durable Medical Equipment Home Mechanical Ventilation Devices: Invasive, Noninvasive, and Multifunction
Fallback criteria: If InterQual CP cannot determine medical necessity, refer to InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD

BIPAP devices (HCPCS E0470, E0471)

Refer to the Indiana Health Coverage Programs Provider Reference Module for state-specific clinical coverage criteria for BIPAP devices (age and code applicability noted below).

BIPAP devices (HCPCS E0470, E0471): Refer to Indiana Health Coverage Programs Provider Reference Module: Durable and Home Medical Equipment and Supplies for medical necessity clinical coverage criteria for BIPAP devices (HCPCS codes E0470 and E0471)

Referenced Codes

Referenced HCPCS for BIPAPHCPCS

E0470	Bilevel PAP device, without backup rate, used for sleep apnea
E0471	Bilevel PAP device, with backup rate, used for sleep apnea

Referenced HCPCS for ventilators (example trilogy)HCPCS

E0465	Trilogy mechanical ventilator (example code referenced)
E0466	Trilogy mechanical ventilator (example code referenced)

Provider Action Items & Documentation Requirements

Documentation Required

Use referenced clinical criteria

Apply the listed hierarchy when determining medical necessity and use the referenced state or InterQual clinical criteria for device-specific decisions. For BIPAP devices (HCPCS E0470, E0471) follow the Indiana Health Coverage Programs Provider Reference Module: Durable and Home Medical Equipment and Supplies. For mechanical ventilators and respiratory assist devices follow InterQual CP: Durable Medical Equipment Home Mechanical Ventilation Devices: Invasive, Noninvasive, and Multifunction; if medical necessity cannot be determined using InterQual CP, refer to InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD.

E0470
E0471
E0465
E0466

Background & Definitions

This policy outlines the ordered sources to determine medical necessity for durable medical equipment and related supplies. It delegates specific device criteria to third-party and state references: providers are to apply federal, state, and contractual requirements first, then InterQual CP: Durable Medical Equipment, then InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD, followed by CMS DME MAC and UnitedHealthcare Community Plan policy. For mechanical ventilators, the policy refers providers to InterQual CP: Durable Medical Equipment Home Mechanical Ventilation Devices: Invasive, Noninvasive, and Multifunction with fallback to InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD if necessary. For BIPAP devices (HCPCS E0470, E0471), the policy directs providers to the Indiana Health Coverage Programs Provider Reference Module: Durable and Home Medical Equipment and Supplies.

Referenced Clinical Guidance

Referenced clinical evidence/version: InterQual CP and InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD. The policy history notes that references were updated (InterQual Medicare replaced with InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD) and that the Clinical Evidence section was removed from the policy.

Policy Revision History

2025-02-01revisedLatest

Coverage rationale language updated and references to InterQual guidance replaced/clarified: InterQual Medicare reference replaced with InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD; ventilator section revised to refer to InterQual CP: Durable Medical Equipment Home Mechanical Ventilation Devices (Invasive, Noninvasive, and Multifunction) with fallback to InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD.

2025-02-01removedLatest

Removed previous coverage statements that ventilators are covered to treat neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to COPD.