ModifiedUnitedHealthcarePolicy BIP048.O

Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies: CA – UnitedHealthcare West Benefit Interpretation Policy

Defines UnitedHealthcare West coverage criteria, inclusions, exclusions, and related requirements for DME, prosthetic devices, corrective appliances/orthotics (non-foot orthotics), and medical supplies for California members, including reference to state-mandated coverage statutes and cross-reference to a detailed DME/Prosthetics grid policy.

Policy Summary

PayerUnitedHealthcare

PolicyDurable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies: CA – UnitedHealthcare West Benefit Interpretation Policy

Policy CodePolicy BIP048.O

Change TypeRevised

Effective DateJan 1, 2026

Next Review Date

Key ActionVerify member-specific coverage, limitations, and exclusions against the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB); EOC/SOB governs if discrepancy exists.

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.

3Covered categories (DME, Prosthetics, Medical Supplies)

10+Examples of included supply types

MultipleState-mandated references (CA statutes cited)

Defines UnitedHealthcare West coverage criteria, inclusions, exclusions, and related requirements for Durable Medical Equipment (DME), prosthetic devices, corrective appliances/orthotics (non-foot orthotics), and medical supplies for California members. The policy cross-references state-mandated statutes and directs users to the detailed Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics and Medical Supplies Grid policy for the list of covered and non-covered items and specific coverage criteria.

Providers and members should verify member-specific coverage, limitations, and exclusions in the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB), which governs if discrepancies exist. The policy version BIP048.O replaces and archives prior version BIP048.N and includes updated instruction to refer to the EOC/SOB for coverage eligibility of advanced prosthetics (e.g., bionic, myoelectric, microprocessor controlled, or computerized prosthetics).

Key Policy Facts

policy_numberBIP048.O

effective_dateJanuary 1, 2026

last_reviewJanuary 1, 2026

statusMODIFIED

subjectDurable Medical Equipment (DME), Prosthetics, Non-Foot Orthotics, and Medical Supplies

Medical-Necessity / Coverage Criteria

Durable Medical Equipment (DME) Coverage Criteria

Covered when ALL of the following are met:

ALL of the following

The equipment meets the definition of Durable Medical Equipment (DME).
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.
The equipment is used in the member's home (home defined to include own dwelling, apartment, relative's home, home for the aged, or some other institution but not acute care, rehabilitation, or skilled nursing facilities).

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

Covered when ALL of the following are met:

ALL of the following

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

Coverage for Related Services and Repairs

Covered when the following conditions apply:

ALL of the following

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, replacement, and adjustments of DME items, Prosthetic Devices, and corrective appliances/Orthotics (Non-foot Orthotics) for owned, purchased, or rented equipment, except where contractually the rented-item provider is responsible.
Extensive adjustment is covered as repair when, per manufacturer recommendations, maintenance requires an authorized technician (e.g., breaking sealed components or specialized testing equipment).
Adjustment of Prosthetic Devices or corrective appliances/Orthotics (non-foot orthotics) when required by normal wear and tear or a significant change in the member's physical condition and ordered by a physician.

Provider Actions & Billing Notes

Prior Authorization

Pre-certification may be required

Pre-certification may be required for repairs, replacement, and adjustments of DME and prosthetic devices; market pre-certification processes vary by plan.

Market pre-certification processes vary by plan; check the member's plan for specific requirements.

Documentation Required

Medical necessity determination

Prosthetic and orthotic items must be determined medically necessary by the member's network medical group or UnitedHealthcare. Providers should document medical necessity accordingly.

Document the clinical rationale and physician determination supporting medical necessity in the medical record.

Billing Rule

Rented item repair responsibility

Repairs, replacement, and adjustments for rented items/devices are the contractual responsibility of the item/device provider.

For rented equipment, coordinate with the rental item's contractual provider for repair, replacement, and adjustment obligations per contract.

Documentation Required

Refer to member EOC/SOB

Verify member-specific coverage, limitations, and exclusions against the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB); the EOC/SOB governs if a discrepancy exists.

If this policy and the member's EOC/SOB conflict, the EOC/SOB provision will govern.
Refer to the member's EOC/SOB to determine eligibility for items such as bionic, myoelectric, microprocessor controlled, or computerized prosthetics.

Definitions & Background

Provides definitions used in the policy: Durable Medical Equipment (DME) (equipment that withstands repeated use, serves a medical purpose, is generally not useful absent illness or injury, and is appropriate for home use), Orthotics (devices designed to support a weakened body part; excludes foot orthotics/specialized footwear for diabetic foot disease), and Prosthetic Devices (articles or equipment that replace all or part of an internal body organ or its function, with permanence judged by medical record and attending physician).

References California Health and Safety Code requirements, including Section 1367.06 (coverage for inhaler spacers, nebulizers, and peak flow meters when medically necessary for pediatric asthma, requirements for education, quantity limits that do not inhibit appropriate treatment, expeditious processes for additional/replacement devices, and disclosure in the EOC) and Section 1367.18 (group plan obligation to offer orthotic and prosthetic device coverage and related terms and utilization review for medical necessity). The policy also cites state law requiring prosthetic devices to restore speech incident to laryngectomy.

Cross-references related policies and guidance: the Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid for specific covered and non-covered item lists, and other related policies (e.g., Diabetic Management, Home Health Care, Shoes and Foot Orthotics).

Notes that covered benefits are listed across the Federal/State Mandated Regulations, State Market Plan Enhancements, and Covered Benefits sections; all services must be medically necessary; and instructs verification of plan-specific provisions in the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB).

Definitions

Evidence / Reference

Policy Summary

PayerUnitedHealthcare

PolicyDurable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies: CA – UnitedHealthcare West Benefit Interpretation Policy

Policy CodePolicy BIP048.O

Change TypeRevised

Effective DateJan 1, 2026

Next Review Date

Key ActionVerify member-specific coverage, limitations, and exclusions against the member's Evidence of Coverage (EOC)/Schedule of Benefits (SOB); EOC/SOB governs if discrepancy exists.

SourceLink

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Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies: CA – UnitedHealthcare West Benefit Interpretation Policy

Coverage Summary

Medical-Necessity / Coverage Criteria

Provider Actions & Billing Notes

Policy Identifiers & Codes

Definitions & Background

Revision History