CurrentUnitedHealthcarePolicy CSO32ID.B

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

State-specific UnitedHealthcare medical policy governing durable medical equipment (DME), orthotics, medical supplies, and repairs/replacements for members in Idaho (including Idaho Medicaid Plus). It directs users to Idaho Administrative Code IDAPA 16 and the Idaho Medicaid Provider Handbook for clinical medical necessity criteria.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CSO32ID.B

Change TypeRevised; Clarified

Effective DateAug 1, 2025

Next Review Date

Key ActionProviders must use Idaho Administrative Code IDAPA 16 and the Idaho Medicaid Provider Handbook - Suppliers as the source for clinical coverage criteria and documentation requirements when submitting claims or prior authorization requests for DME, orthotics, supplies, and repairs/replacements in Idaho.

POLICY UPDATE CHANGES

Coverage Rationale updated to reference Idaho Administrative Code and Idaho Medicaid Provider Handbook as sources for medical necessity criteria.

Updated Coverage Rationale reference links to Idaho Administrative Code and Idaho Medicaid Provider Handbook.

StateJurisdiction

CSO32ID.BPolicy Number

IDAPA/Handbook/PDACExternal Sources

Coverage Summary

State-specific UnitedHealthcare medical policy governing durable medical equipment (DME), orthotics, medical supplies, and repairs/replacements for members in Idaho (including Idaho Medicaid Plus). It directs users to Idaho Administrative Code IDAPA 16 and the Idaho Medicaid Provider Handbook - Suppliers for clinical medical necessity criteria and applies only in the state of Idaho.

Policy Metadata

Policy NumberCSO32ID.B

SubjectDurable Medical Equipment; Orthotics, Medical Supplies, and Repairs/Replacements (Idaho)

JurisdictionState-specific (Idaho)

StatusCURRENT

Effective DateAugust 1, 2025

Last ReviewAugust 20, 2025

Medical Necessity Determination

When determining medical necessity, apply the following in order:

CMS MAC guidance: Centers for Medicare & Medicaid Services (CMS DME Medicare Administrative Contractor (MAC) guidance)
Federal/State/Contractual requirements: Applicable federal, state, and contractual requirements
In the event of a conflict, federal, state, or contractual requirements govern.
Related UHC Community Plan Medical Policies: Related UnitedHealthcare Community Plan Medical Policies
Idaho administrative rules and provider handbook: Refer to Idaho Department of Health and Welfare Administrative Code IDAPA 16 and the Idaho Medicaid Provider Handbook - Suppliers for medical necessity clinical coverage criteria for DME, orthotics, medical supplies, and repairs/replacements
Providers must use IDAPA 16 and the Idaho Medicaid Provider Handbook - Suppliers as the source for clinical coverage criteria and documentation requirements when submitting claims or prior authorization requests in Idaho.

Order of application: Apply CMS MAC guidance, then federal/state/contractual requirements, then related UnitedHealthcare Community Plan Medical Policies, and refer to Idaho IDAPA 16 and the Idaho Medicaid Provider Handbook for DME/orthotics/supplies/repairs replacements.

Provider Actions & Billing Rules

Documentation Required

Follow state administrative code and provider handbook for medical necessity

Providers must use Idaho Administrative Code IDAPA 16 and the Idaho Medicaid Provider Handbook - Suppliers as the source for clinical coverage criteria and documentation requirements when submitting claims or prior authorization requests for DME, orthotics, supplies, and repairs/replacements in Idaho.

Billing Rule

Use PDAC for coding clarification

UnitedHealthcare has established the PDAC as a source for correct coding and coding clarification for DMEPOS; providers should reference PDAC for correct coding and pricing.

Background

This policy is intended to assist interpretation of UnitedHealthcare standard benefit plans but defers to federal, state, or contractual requirements where those requirements differ or conflict with the standard benefit plan. When determining medical necessity, apply guidance in the following order: CMS DME MAC guidance, applicable federal, state, and contractual requirements, and related UnitedHealthcare Community Plan Medical Policies.

For medical necessity clinical coverage criteria for DME, orthotics, medical supplies, and repairs/replacements in Idaho, refer to the Idaho Department of Health and Welfare Administrative Code IDAPA 16 and the Idaho Medicaid Provider Handbook - Suppliers. UnitedHealthcare may also use third-party tools (for example, InterQual) to assist in administering benefits, and has established the PDAC as a source for correct coding and coding clarification for DMEPOS.

Revision History

08/20/2025material_changeLatest

Coverage Rationale updated to reference Idaho Administrative Code and Idaho Medicaid Provider Handbook as sources for medical necessity criteria. Replaced prior internal InterQual and UnitedHealthcare-specific guidance; removed several definitions and sections (DME, Irreparable Medical Supplies, RUL) and archived previous policy CSO32ID.A. Detail: Replaced "UnitedHealthcare Community Plan Medical Policy" language; removed references to InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD; replaced coverage guidelines with instruction to refer to Idaho Department of Health and Welfare Administrative Code IDAPA 16 and the Idaho Medicaid Provider Handbook - Suppliers for medical necessity clinical coverage criteria for durable medical equipment, orthotics, medical supplies, and repairs/replacements.

08/01/2025non_material_clarification

Updated Coverage Rationale reference links to Idaho Administrative Code and Idaho Medicaid Provider Handbook. Detail: Reference links refreshed to current documents (Accessed April 11, 2025).