CurrentUnitedHealthcarePolicy BIP048.O

Dme Prosthetics Corrective Appliances Medical Supplies Ca

UnitedHealthcare West benefit interpretation policy BIP048.O defines coverage, medical necessity criteria, and exclusions for DME, prosthetics, non-foot orthotics, corrective appliances and medical supplies, including federal/state mandated requirements and repair/replacement rules. It references member Evidence of Coverage/Schedule of Benefits for eligibility and specific benefit limits.

Policy Summary

PayerUnitedHealthcare

PolicyDme Prosthetics Corrective Appliances Medical Supplies Ca

Policy CodePolicy BIP048.O

Change TypeRevised

Effective DateJanuary 1, 2026

Next Review Date

Key ActionObtain pre-certification/prior authorization per member plan and document medical necessity referencing the member's EOC/SOB.

SourceLink

POLICY UPDATE CHANGES

Updated instruction to refer to the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB) for bionic, myoelectric, microprocessor controlled, or computerized prosthetics to determine coverage eligibility.

Policy effective date set to January 1, 2026 and marked as policy version BIP048.O.

MultipleCovered Indications

12+Not Covered Categories

Coverage Summary

UnitedHealthcare West Benefit Interpretation Policy BIP048.O provides coverage rules and interpretations for Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies. The policy consolidates applicable federal and state mandated regulations and plan-level interpretations to define covered items, exclusions, repair and replacement rules, and related requirements.

Medical-Necessity Criteria

Durable Medical Equipment (DME) Coverage Criteria

May be rented, purchased, or repaired and must meet all of the following criteria:

ALL of the following

Durable Medical Equipment (DME) Coverage Criteria
- Definition: The equipment meets the definition of DME
- Medical Necessity: The equipment is necessary and reasonable for the treatment of a member's illness or injury or to improve the functioning of his/her malformed body member
- Place of Use: The equipment is used in the member's home (does not include acute care, rehabilitation, or skilled nursing facilities; home may be dwelling, apartment, relative's home, home for the aged, or similar institution)

Prosthetic and Corrective Appliances/Orthotics (Non-Foot Orthotics) Coverage Criteria

Including custom made or custom fitted and must meet all the following criteria:

Definition: The item meets the definition of Prosthetic and corrective appliances/Orthotics (non-foot Orthotics)
Medical Necessity: Is medically necessary as determined by the member's network medical group or UnitedHealthcare

Additional Coverage: Coverage includes fitting and adjustment of these devices, their repair or replacement (unless due to loss, misuse, malicious breakage, or gross neglect), and services to determine whether the member needs a prosthetic or orthotic device

Coverage for Related Services and Supplies

Coverage applicable to DME and Prosthetic/Orthotic items when medically necessary:

Supplies for effective use: Supplies for DME items or Prosthetic Devices (e.g., oxygen, batteries for an artificial larynx, stump sock, or shrinker) only when they are necessary for the effective use of the item/device
Repairs and replacements: Repairs, replacement, and adjustments of DME items, Prosthetic Devices, and corrective appliances/Orthotics (Non-foot Orthotics) for owned, purchased, or rented equipment (repairs/replacement for rented items are contractual responsibility of item/device provider)
Essential accessories: Repairs may include replacement of essential accessories (hoses, tubes, mouth pieces, etc.)
Extensive adjustment is covered as repair when maintenance per manufacturer's recommendations must be performed by an authorized technician

Medical Supplies Coverage Criteria

Medical supplies and materials needed to treat an illness or injury are covered when used/provided under direct supervision of the network provider:

Use under supervision: Used or provided while the member is treated in the network provider's office, during the course of an illness or injury, or stabilization of an injury or illness, under the direct supervision of the network provider
Examples: gauzes, ointments, bandages, slings and casts; disposable supplies when necessary for effective use of Durable Medical Equipment

Not Covered / Exclusions

Not Covered

Items and circumstances explicitly excluded from coverage:

Not Covered: Accessories for portability or travel

Not Covered: A second piece of DME for the same or similar medical purpose as existing DME (only one item that meets minimal functional needs will be covered)

Not Covered: Bionic, myoelectric, microprocessor controlled, or computerized prosthetics unless member has the benefit in their EOC/SOB

Not Covered: Communication devices: computers, PDAs, and any speech-generating devices (except artificial larynxes)

Not Covered: Deluxe upgrades that are not medically necessary

Not Covered: Home and/or car modifications to accommodate the member's condition

Not Covered: Medical supplies that are disposable or consumable outside the defined coverage or are part of the home health benefit

Not Covered: Non medically necessary optional modifications or attachments to DME, corrective appliances/Orthotics, or Prosthetics for comfort or convenience

Not Covered: Replacement or repair of items due to malicious breakage, damage, neglect, or abuse

Not Covered: Replacement or repair of lost or stolen equipment

Not Covered: Routine periodic adjustment (testing, cleaning, regulating, checking) for which the owner is generally responsible

Provider Actions

Prior Authorization

Pre-certification may be required

Coverage for repairs, replacements, and some DME items may require pre-certification; the market pre-certification process varies and prior authorization should be obtained per member plan.

Documentation Required

Medical necessity determination

Items must be determined medically necessary by the member's network medical group or UnitedHealthcare; document medical necessity in the medical record and reference member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB) for benefit eligibility.

Document medical necessity in the member's medical record and reference the member's EOC/SOB to determine coverage eligibility.

Billing Rule

Repairs/replacement responsibility for rented items

Repairs/replacement for rented DME items are the contractual responsibility of the item/device provider; the plan or the member's network medical group/UnitedHealthcare may opt to repair or replace owned items.

Repairs/replacement for rented DME are the contractual responsibility of the device provider; plan may opt to repair or replace owned items.

Background & Definitions

This policy consolidates applicable federal and state mandated regulations (for example California Health and Safety Code provisions) with plan-level interpretations to define coverage for DME, prosthetics, orthotics, and medical supplies. It explains that items may be rented, purchased, or repaired when they meet DME or prosthetic/orthotic definitions and are medically necessary and used in the home.

Repair and replacement rules: Repairs, replacements, and adjustments are covered for owned, purchased, or rented equipment when medically necessary, including replacement of essential accessories; repairs/replacement for rented items are the contractual responsibility of the item/device provider. Replacements are covered for damage beyond repair with normal wear and tear, when repair costs exceed new purchase price, or when a significant change in the member's physical condition occurs; the plan or member's network medical group may opt to repair or replace. Some repairs or replacements may require pre-certification and maintenance that must be performed by authorized technicians is treated as repair when specified by the manufacturer.

Refer to member Evidence of Coverage/Schedule of Benefits (EOC/SOB) for specific eligibility, benefit limits, and any plan-specific provisions—if there is a discrepancy between this policy and the member's EOC/SOB, the EOC/SOB governs.

References: Medicare Coverage Summary: Durable Medical Equipment (DME), Prosthetics, Orthotics (Non-Foot Orthotics), Nutritional Therapy, and Medical Supplies Grid. Accessed October 28, 2025.

Term	Definition
Orthotics	Devices that are designed to support a weakened body part; manufactured or custom-fitted to an individual member; excludes foot orthotics or specialized footwear for diabetic foot disease.
Durable Medical Equipment (DME)	Equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful in the absence of an illness or injury, and is appropriate for use in the home.
Prosthetic Devices	Articles or equipment (other than dental) that replace all or part of an internal body organ or replace function of a permanently inoperative or malfunctioning internal body organ; permanence judged by medical record and attending physician.

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