ModifiedUnitedHealthcarePolicy CSO32OH.D

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

UnitedHealthcare medical policy applicable only to members in Ohio that defines coverage, medical necessity determination order, definitions, and references for DME, orthotics, related supplies, repairs/replacements, and specific device classes (ventilators, PAP, enteral pumps, cranial remolding, insulin pumps, etc.). It cross-references Ohio Administrative Code rules and InterQual criteria for clinical coverage determinations.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CSO32OH.D

Change TypeRevisions and removals (material and non-material)

Effective DateFeb 1, 2025

Next Review Date

Key ActionProviders must document medical necessity consistent with Ohio Administrative Code rules and InterQual CP/Medicare criteria as referenced by the policy when requesting DME, repairs, replacements, or supplies.

POLICY UPDATE CHANGES

Updated Coverage Rationale language about DME medical necessity and replaced InterQual reference with InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD (02/01/2025).

Removed coverage statements that ventilators and respiratory assist devices are covered without further review for persons younger than 2 years of age and specific condition-based coverage language.

Removed reference links to several related policies and retired Patient Lifts and Speech Generating Devices references (06/01/2025).

Removed definition of Medical Supplies from Definitions section; updated definitions of Durable Medical Equipment (DME) and Reasonable Useful Lifetime.

Added language indicating enteral pumps are covered as DME and clarified referral for formula information.

Supporting Clinical Evidence section removed and previous policy version archived.

Ohio-only

MultipleCovered Device Categories

InterQualPrimary Clinical Criteria

Coverage Summary

This policy applies to UnitedHealthcare standard benefit plans for members located in Ohio-only and defines coverage, medical necessity determination order, definitions, and references for durable medical equipment (DME), orthotics, related supplies, repairs/replacements, and specific device classes.

The policy's coverage stance is mixed and it uses InterQual as the primary clinical criteria source, applying clinical guidelines in a specified order that includes federal/state (Ohio Administrative Code) and contractual requirements, InterQual CP, UnitedHealthcare medical policies, CMS DME MAC guidance, and InterQual Medicare for ventilators when indicated.

High-level dates: Effective: 2025-02-01; Last review: 2025-06-01. The document is identified as Policy Number CSO32OH.D.

Policy Metadata

Geographic ScopeOhio-only

Primary Clinical Criteria SourceInterQual referenced (InterQual CP and InterQual Medicare for ventilators)

Coding SourcePDAC adopted (CMS/PDAC for DMEPOS coding)

Effective Date2025-02-01

Last Review2025-06-01

Policy NumberCSO32OH.D

Medical Necessity Criteria

General Coverage / Medical Necessity Determination

General coverage and medical necessity determinations follow Ohio Administrative Code and UnitedHealthcare ordering of clinical guidelines. Covered DME, orthoses, prostheses, and supplies are evaluated for medical necessity using the listed criteria.

ALL of the following

Services must meet the definitions and general provisions in Ohio Administrative Code Chapter 5160-10-01 (Durable medical equipment; prostheses, orthoses, and supplies).
Clinical medical necessity will be determined using the following order of application: 1) Federal, state (Ohio Administrative Code), and contractual requirements; 2) InterQual CP: Durable Medical Equipment; 3) UnitedHealthcare Community Plan Medical Policy; 4) InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD (when applicable).
Items that are implantable, fully implanted devices, or included as part of the surgical benefit are not covered as DME and should be adjudicated under the applicable medical/surgical benefit.

ALL of the following

Coding

Protective helmet (not cranial remolding device)HCPCSNot Covered

A8000	Protective helmet (example code list starts A8000-A8004 per policy)
A8001
A8002
A8003
A8004

Ventilator example codes (not to be billed as CPAP/Bi-level codes)HCPCS

E0465	Trilogy mechanical ventilator (example referenced)
E0466	Trilogy mechanical ventilator (example referenced)
E0470	Bi-level PAP, flow limited, pressure recommended (referenced as bi-level PAP mode)
E0471	Bi-level PAP, second code referenced
E0601	CPAP (not appropriate coding for ventilator billed as CPAP)

Provider Actions & Billing Rules

Documentation Required

Follow Ohio Administrative Code and InterQual criteria

Providers must document medical necessity consistent with Ohio Administrative Code rules and InterQual CP/Medicare criteria when requesting durable medical equipment (DME), repairs, replacements, or supplies. Documentation should follow the policy's specified order of clinical criteria application and reference relevant OAC rules when applicable.

Ohio Administrative Code (Chapter 5160-10 and specific rules referenced in policy)
InterQual CP: Durable Medical Equipment (Home Mechanical Ventilation Devices where applicable)
InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD (if InterQual CP does not resolve medical necessity)

Billing Rule

Do not bill ventilators as CPAP or bi-level PAP codes

Background & Definitions

This policy interprets UnitedHealthcare standard benefit plans for Ohio and explicitly defers to federal, state (Ohio Administrative Code), or contractual requirements when those requirements differ from standard benefit plan terms; in the event of a conflict, the federal/state/contractual requirements govern.

UnitedHealthcare uses InterQual for primary medical necessity criteria and applies clinical guidelines in an ordered sequence that includes Ohio Administrative Code rules, InterQual CP for Durable Medical Equipment, UnitedHealthcare Community Plan Medical Policy, CMS DME MAC guidance, and InterQual Medicare for ventilator determinations when needed.

The policy references specific Ohio Administrative Code rules for clinical criteria and coverage details, including Rule 5160-10-25 (lactation pumps), Rule 5160-10-14 (compression garments/lymphedema stockings), Chapter/Rule 5160-10 for medical supplies, Rule 5160-10-01 and Rule 5160-10-02 for repair/replacement limitations, and Rule 5160-10-22 for ventilators.

Durable Medical Equipment (DME) definition

Medical equipment that is suitable for use in any setting of normal life activities, generally not useful in absence of disability/illness/injury, reusable or removable, non-implantable, primarily serves a medical purpose, and meets federal/state definition of DME.

Medicare Determinations

Medicare determinations referenced by this policy include the Ventilators NCD (type: NCD).

For ventilators and respiratory assist devices (age 2 and older), medical necessity should first be determined using InterQual CP: Durable Medical Equipment Home Mechanical Ventilation Devices; if medical necessity cannot be resolved using those criteria, refer to InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD for determination.

If the InterQual criteria do not resolve medical necessity questions for ventilators, the policy advises referral to the listed Medicare NCD as the next step.

Revision History

2025-06-01related_policies_removed

Related Policies removed and links updated; retired Patient Lifts and Speech Generating Devices references and removed link to Mobility Devices, Options, and Accessories. Archived prior policy version CSO32OH.C (06/01/2025).

2025-02-01coverage_criteria_updated

Replaced InterQual reference with InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD and changed ventilator coverage/clinical criteria. Mechanical ventilator guidance revised to refer first to InterQual CP: Durable Medical Equipment Home Mechanical Ventilation Devices: Invasive, Noninvasive, and Multifunction and, if unresolved, to InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD. Marked as material change: revised coverage rationale and ventilator criteria (02/01/2025).

2025-02-01

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CSO32OH.D

Change TypeRevisions and removals (material and non-material)

Effective DateFeb 1, 2025

Next Review Date

On This Page

Medical supplies used with covered DME are covered when necessary for effective use of the device (e.g., oxygen tubing or mask; batteries for power wheelchairs and prosthetics; tubing for a delivery pump).
Coverage of replacement, repair, and upgrade is subject to Ohio Administrative Code Rule 5160-10-02 and Rule 5160-10-01 and may require documentation that repair or replacement is medically necessary and not due to misuse or neglect.

ALL of the following

Ventilators and respiratory assist devices for individuals 2 years of age and older: apply InterQual CP: Durable Medical Equipment Home Mechanical Ventilation Devices: Invasive, Noninvasive, and Multifunction for medical necessity determinations. If medical necessity cannot be determined using these InterQual CP criteria, refer to InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD.
Refer to Ohio Administrative Code Rule 5160-10-22 for additional state-specific requirements for ventilators.

ALL of the following

Breast pumps: medical necessity and coverage follow Ohio Administrative Code Rule 5160-10-25 (DMEPOS: lactation pumps).

ALL of the following

Lymphedema stockings for the arm: medical necessity and coverage follow Ohio Administrative Code Rule 5160-10-14 (DMEPOS: compression garments).

ALL of the following

Medical supplies: Covered when necessary for effective use of covered DME. Refer to Ohio Administrative Code Chapter 5160-10 for medical supplies coverage and provider requirements.

ALL of the following

Repair, Replacement, and Upgrade: Coverage limitations and exclusions are governed by Ohio Administrative Code Rule 5160-10-01 and Rule 5160-10-02. Repair and replacement of DME may be covered when items are necessary for continued function and not due to misuse, and when documentation supports medical necessity for replacement or upgrade.
For cochlear implant external component repairs/replacements (speech processor, microphone, transmitter coil), evaluate under the DME benefit per applicable federal, state, or contractual requirements; initial cochlear implant and internal device components are adjudicated under the medical/surgical benefit at time of implantation.

ALL of the following

Cochlear implants and external components: The initial cochlear implant and internal components are considered under the medical benefit at the time of the initial surgery. Repair and replacement of external components (speech processor, microphone, transmitter coil) are considered under the DME benefit. Refer to applicable federal, state, or contractual requirements to determine DME benefit applicability for repairs or replacements.

ALL of the following

Implanted devices: Any device, appliance, pump, machine, stimulator, or monitor that is fully implanted into the body is not covered as DME. If covered, the device is covered as part of the surgical/medical benefit as of the surgical service.

ALL of the following

Cranial remolding orthosis: Refer to the Medical Policy titled Plagiocephaly and Craniosynostosis Treatment (for Ohio Only) for medical necessity criteria. Note that protective helmets (HCPCS A8000-A8004) are considered safety devices, not cranial remolding devices.

ALL of the following

Enteral pumps: Enteral pumps are covered as DME. Refer to the Medical Policy titled Enteral Nutrition (Oral and Tube Feeding) (for Ohio Only) for coverage details and information regarding formulas.

ALL of the following

Insulin pumps: Durable and disposable insulin pumps are covered. Refer to the Medical Policy titled Insulin Delivery for Managing Diabetes (for Ohio Only) for clinical coverage criteria and any prior authorization or documentation requirements.

ALL of the following

Orthotic braces: Orthotic braces that stabilize an injured body part and braces to treat curvature of the spine are considered DME. Examples include knee orthotics (KO), ankle-foot orthotics (AFO), lumbar-sacral orthotics (LSO), thoracic-lumbar-sacral orthotics (TLSO), and necessary shoe adjustments to accommodate braces.
Specific HCPCS codes defined as orthotics are covered as DME per applicable coding and Ohio Administrative Code provisions.

ALL of the following

Tracheo-esophageal and voice aid prosthetics: Covered as DME when meeting Ohio Administrative Code and policy criteria.

ALL of the following

When state, federal, or contractual requirements differ from these policy statements, those requirements take precedence. Providers must follow Ohio Administrative Code provisions for documentation, prior authorization, and billing to support medical necessity determinations.

Clinical criteria order of application

When determining medical necessity, apply the following clinical criteria order and preserve this ordering when referencing clinical guidance resources.

ALL of the following

1. Federal, state (Ohio Administrative Code), and contractual requirements.
2. InterQual CP: Durable Medical Equipment.
3. UnitedHealthcare Community Plan Medical Policy.
4. InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD (when applicable).

ALL of the following

Apply InterQual CP criteria first for DME clinical determinations. If InterQual CP does not resolve medical necessity (e.g., no applicable rule), then refer to InterQual Medicare criteria as the fallback per policy.

Ventilators and Respiratory Assist Devices (>= 2 years of age)

Ventilators and respiratory assist devices for individuals aged 2 years and older are adjudicated using InterQual CP criteria with an InterQual Medicare fallback when needed. State rule references apply.

ALL of the following

For individuals >= 2 years of age, apply InterQual CP: Durable Medical Equipment Home Mechanical Ventilation Devices: Invasive, Noninvasive, and Multifunction to determine medical necessity for mechanical ventilators and respiratory assist devices.
If medical necessity cannot be determined using InterQual CP criteria, refer to InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD as the fallback guidance.
Ventilators used solely to deliver continuous or intermittent positive airway pressure (CPAP or bi-level PAP) are not considered medically necessary as ventilator therapy for adults and children >= 2 years when the device is operated only in PAP mode; billing must use the appropriate PAP codes (e.g., E0601 for CPAP) rather than ventilator codes.
Refer to Ohio Administrative Code Rule 5160-10-22 for additional state-specific ventilator requirements.

ALL of the following

Examples and coding: Ensure correct billing codes are used per PDAC guidance and CMS instructions; ventilator billing using CPAP or bi-level PAP codes is incorrect coding even if the ventilator is only being used in CPAP or bi-level mode.

Breast Pumps

Breast pumps are covered per Ohio rule for lactation pumps.

ALL of the following

Medical necessity and coverage for breast (lactation) pumps follow Ohio Administrative Code Rule 5160-10-25 (DMEPOS: lactation pumps).

ALL of the following

Providers should follow state rule for documentation and potential prior authorization requirements where applicable.

Lymphedema Stockings for the Arm

Lymphedema stockings for the arm are covered when criteria in the Ohio Administrative Code are met.

ALL of the following

Coverage and medical necessity for arm lymphedema compression garments (stockings) are determined by Ohio Administrative Code Rule 5160-10-14 (DMEPOS: compression garments).
Documentation must support diagnosis of lymphedema and medical need for compression garment therapy per state rule.
Replacement frequency, fitting requirements, and supplier/provider responsibilities follow the Ohio Administrative Code provisions.

Medical Supplies

Medical supplies used with covered DME are covered when necessary for effective use; follow Ohio Code and policy for provider obligations.

ALL of the following

Medical supplies (e.g., oxygen tubing, masks, batteries for power wheelchairs, tubing for delivery pumps) are covered when necessary for effective use of covered DME.
Refer to Ohio Administrative Code Chapter 5160-10 for specifics on medical supplies coverage, supplier requirements, and documentation.

ALL of the following

Supplies that are primarily for convenience, administrative use, or not necessary for device function are not covered unless state/contractual provisions indicate otherwise.

Repair/Replacement/Upgrade

Repair, replacement, and upgrades of DME are governed by Ohio Administrative Code rules and require documentation of medical necessity and that the need is not due to misuse.

ALL of the following

Coverage for repair, replacement, and upgrade is defined by Ohio Administrative Code Rule 5160-10-02 (repairs) and Rule 5160-10-01 (general provisions).
Repair is covered when reasonable and necessary to restore function of covered DME; replacement or upgrade is covered when the device is no longer repairable or when clinical progress or change in medical condition requires a different device.
Items lost, stolen, or damaged due to misuse, abuse, or neglect are generally not covered for replacement without evidence of medical necessity or exceptional circumstances per state rule.
Documentation: Supplier and provider must document prior device history, reason for repair/replacement/upgrade, clinical necessity, and any relevant durable medical equipment maintenance records.

ALL of the following

Cochlear implant external component repairs/replacements are considered under DME repair/replacement provisions; consult federal/state/contractual requirements to determine coverage and any applicable limitations.

ALL of the following

For billing and coding, follow PDAC and HCPCS guidance; repairs and replacement services should be billed with appropriate repair or replacement codes as defined by coding authorities and state rules.

Cochlear Implants and External Components

Cochlear implant coverage is split between the medical benefit for implantation and DME for some external component services.

ALL of the following

The cochlear implant and internal components are considered under the medical benefit at the time of the initial surgery.
Repair and replacement of external components (speech processor, microphone, transmitter coil) are considered under the DME benefit and are subject to DME repair/replacement rules and Ohio Administrative Code provisions.
Providers must consult federal, state, or contractual requirements to determine whether DME benefits apply for repair or replacement of external components and follow documentation and prior authorization rules as applicable.

ALL of the following

Replacement frequency, warranty considerations, and coverage limits for external components are subject to policy and state rules; supplier must provide documentation of need and that repair is not feasible when requesting replacement.

Implanted Devices

Fully implanted devices are excluded from DME coverage and are considered part of the medical/surgical benefit when covered.

ALL of the following

Any device, appliance, pump, machine, stimulator, or monitor that is fully implanted into the body is not covered as DME.
If coverage is applicable, implanted devices are covered under the surgical/medical benefit at the time of the surgical service and must be billed accordingly.

ALL of the following

When determining coverage for partially implantable or external components associated with an implanted device, apply the applicable state and contractual rules to determine whether DME benefits apply for external accessories, repairs, or replacements.

Cranial Remolding Orthosis

Cranial remolding orthoses are addressed under the specific Ohio policy for plagiocephaly and craniosynostosis.

ALL of the following

Refer to the Medical Policy titled Plagiocephaly and Craniosynostosis Treatment (for Ohio Only) for medical necessity criteria for cranial remolding orthoses.
Protective helmets HCPCS A8000-A8004 are considered safety devices and not cranial remolding devices; they are not adjudicated as cranial remolding orthoses for active treatment.

ALL of the following

Documentation must show diagnosis, age-appropriate criteria, and supplier fitting records per the referenced medical policy and Ohio rule when requesting coverage.

Enteral Pumps

Enteral pumps are covered as DME and fall under the enteral nutrition policy for clinical criteria and supplies.

ALL of the following

Enteral feeding pumps are covered as durable medical equipment when medically necessary for tube or oral enteral nutrition delivery.
Refer to the Enteral Nutrition (Oral and Tube Feeding) (for Ohio Only) medical policy for clinical criteria, formula coverage, and required documentation.
Associated supplies (e.g., feeding sets, tubing) are covered when necessary for effective use per Ohio Administrative Code and the enteral nutrition policy.

ALL of the following

Replacement frequency, maintenance, and repair of enteral pumps follow DME repair/replacement rules; suppliers must document reason for repair or replacement.

Insulin Pumps

Insulin pumps, both disposable and durable, are covered per the insulin delivery medical policy.

ALL of the following

Durable and disposable insulin pumps are covered when medical necessity criteria in the Insulin Delivery for Managing Diabetes (for Ohio Only) medical policy are met.
Providers must follow the referenced medical policy for clinical indications, prior authorization requirements, documentation, and coverage limitations for insulin pumps and associated supplies (e.g., infusion sets).

ALL of the following

Replacement, repair, and upgrade of insulin pumps are subject to DME repair/replacement rules and warranty considerations; documentation supporting medical necessity is required.

Orthotic Braces

Orthotic braces that stabilize injured body parts or treat spinal curvature are covered as DME when medically necessary.

ALL of the following

Orthotic braces (e.g., knee orthotics (KO), ankle-foot orthotics (AFO), lumbar-sacral orthotics (LSO), thoracic-lumbar-sacral orthotics (TLSO)) are considered DME when used to stabilize an injured body part or to treat spinal curvature.
Necessary shoe adjustments to accommodate braces are included when clinically required.
Coverage follows HCPCS coding definitions for orthotics and Ohio Administrative Code provisions; providers must supply documentation of clinical indication, fitting, and medical necessity.

ALL of the following

Custom fabrication, prefabricated devices, and replacement frequency are subject to policy and Ohio Administrative Code limits; prior authorization may be required per the referenced UnitedHealthcare or state requirements.

Tracheo-Esophageal and Voice Aid Prosthetics

Tracheo-esophageal and voice aid prosthetics are covered as durable medical equipment when meeting policy and state criteria.

ALL of the following

Tracheo-esophageal prosthetics and voice aid prosthetics are covered as DME when meeting Ohio Administrative Code and UnitedHealthcare policy criteria.
Repair and replacement of these devices follow DME repair/replacement rules and require documentation of clinical need and prior device history.

ALL of the following

Providers should consult applicable state rules for any limits, supplier requirements, or documentation standards.

Ventilators must not be billed using CPAP or bi-level PAP HCPCS codes. Billing a ventilator with CPAP (E0601) or bi-level PAP codes (E0470, E0471) is incorrect coding and may result in claim denial.

Prior Authorization

Referral to InterQual criteria for ventilators

For ventilators and respiratory assist devices for patients aged 2 years and older, prior determination of medical necessity should first follow the InterQual CP criteria (Durable Medical Equipment Home Mechanical Ventilation Devices: Invasive, Noninvasive, and Multifunction). If medical necessity cannot be determined using InterQual CP, refer to the InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD.

InterQual CP: Durable Medical Equipment Home Mechanical Ventilation Devices: Invasive, Noninvasive, and Multifunction
InterQual Medicare: Post Acute & Durable Medical Equipment; Ventilators NCD

coverage_statement_removed

Removed prior coverage statements that ventilators and respiratory assist devices are covered without further review for persons younger than 2 years of age and removed condition-specific ventilator coverage language (e.g., neuromuscular disease, thoracic restrictive disease, COPD). Marked as material change (02/01/2025).

2025-02-01definitions_updated

Definitions updated and removed: removed definition of Medical Supplies and updated definitions of Durable Medical Equipment (DME) and Reasonable Useful Lifetime (02/01/2025).

2025-02-01added_cross_reference

Enteral pumps explicitly stated as covered DME and cross-referenced Enteral Nutrition policy (02/01/2025).

2025-02-01clinical_evidence_section_removed

Supporting Clinical Evidence section removed and previous policy version archived (02/01/2025).