UnitedHealthcare DME Coverage & Prior Auth Update

Coverage and Medical Necessity Criteria

General DME Medical Necessity

Durable Medical Equipment (DME), related supplies, and orthotics are medically necessary when:

General DME criteria: (1) Consistent with the state definition of DME and/or Orthotic; (2) The item meets the plan's definition of medically necessary (refer to federal, state, or contractual requirements); (3) Ordered by a physician or by a nurse practitioner, clinical nurse specialist, or physician assistant acting within scope of practice under state law; (4) The item is not otherwise excluded from coverage.

Electric Breast Pump Equipment Criteria

Electric breast pumps are dispensed when ALL of the following minimum device features are met:

Breast pump device features: Adjustable suction pressure with written instructions or automatic mechanism to prevent suction greater than 250 mmHg; adaptable for simultaneous pumping of both breasts (double collection); automatic cycling with an adjustable variable cycling rate (typically 30 to 60 or more cycles per minute); battery option and adapter for alternate power; adjustable or multiple flange sizes (or flexible shields); accessories necessary for pumping two breasts simultaneously; at least two BPA- and DEHP-free collection bottles with spill-proof standard-size caps; accessories and supplies compatible with the pump and made of durable materials able to withstand repeated boiling, washing, and pumping use.suction <= 250 mmHg; cycling rate typically 30-60+ cycles/min

Breast Pump Replacement Criteria

Replacement is allowed when ALL of the following are met:

Breast pump replacement: Pump is older than three years and replacement occurs after expiration of the manufacturer's warranty; replacement and warranty are subject to Louisiana Medicaid DME Provider Manual Section 18.2.>3 years and post-warranty

Electric Breast Pump Supplies

Supply coverage rules:

Breast pump supplies: Electric breast pump supplies are available to the nursing mother once every 180 days; DME providers must obtain prior authorization for replacement supplies.interval = 180 days

Human Milk Storage Bags

Supply provision for lactating beneficiaries:

Storage bags: Medicaid covers 100 human milk storage bags per month for lactating beneficiaries; the Medicaid reimbursement rate on file covers a one-month supply.100 bags/month

Enteral Infusion Pump

Enteral pump coverage conditions:

Enteral infusion pump approval: A standard enteral infusion pump will be approved only with documented evidence that syringe or gravity feedings are unsatisfactory due to complications such as aspiration, diarrhea, dumping syndrome, etc.; Medicaid will pay for rental of a standard enteral infusion pump and accessories.documented complications making gravity/syringe unsatisfactory

Equipment Maintenance, Repair, and Replacement Limitations

Conditions for maintenance/repair reimbursement and exclusions for replacement:

Maintenance reimbursement: Maintenance and repair are reimbursed only when: equipment is covered by Medicaid; is the personal property of the beneficiary; remains medically necessary; is used exclusively by the beneficiary; no other payment source is available; damage is not due to misuse, abuse, neglect, loss, or wrongful disposition by the beneficiary/caregiver/provider; maintenance is performed by a qualified technician; maintenance is not covered under a manufacturer's or provider's warranty; and maintenance is not performed on a duplicate item already being maintained during the maximum limit period.

Replacement exclusions: Medicaid will not replace equipment lost, destroyed, or damaged as a result of misuse, abuse, neglect, loss, or wrongful disposition by the beneficiary, caregiver, or provider (examples include failure to clean/maintain or failure to store securely). If equipment is stolen or destroyed in a fire, a completed police or insurance report describing the specific medical equipment must be submitted with the new prior authorization request. Medicaid may replace equipment when the beneficiary's medical necessity changes and the provider submits required documentation to justify purchase.

Ventilators (≥2 years)

Ventilator coverage stance for members aged 2 years and older:

Ventilator not medically necessary conditions: For members 2 years and older, ventilators are not medically necessary when used only to deliver continuous or intermittent positive airway pressure (including bi-level PAP modes HCPCS E0470 and E0471), or when used for conditions qualifying for RAD devices that are not life‑threatening.

Ventilator medically necessary conditions: Mechanical ventilators (e.g., HCPCS E0465, E0466) are considered medically necessary to treat neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to COPD in certain clinical scenarios; refer to InterQual Medicare Ventilators NCD for detailed clinical criteria. Additionally, all equipment needs must be prior authorized and a rental trial up to three months may be requested unless purchase is justified.

InterQual referenced for clinical criteria; PA required and rental trial guidance applies.

PAP/CPAP Coverage Criteria

Criteria for CPAP/Bi-level PAP coverage for adults and pediatric beneficiaries:

Adult CPAP coverage: Single‑level CPAP is covered when the beneficiary has a diagnosis of obstructive sleep apnea (OSA) documented by an attended facility‑based polysomnogram or a home‑based HSAT AND either (a) AHI ≥ 15 events per hour, OR (b) AHI 5–14 events per hour with documented symptoms (excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia) or comorbidities (hypertension, ischemic heart disease, or history of stroke).AHI >=15 OR (AHI 5-14 with symptoms/comorbidities)

Polysomnographic studies may be performed in a facility‑based sleep lab, in the home, or in a mobile facility; labs must be qualified Medicare/Medicaid providers.

Pediatric CPAP coverage: Single‑level CPAP is covered for beneficiaries under 21 when OSA is documented by an attended, facility‑based polysomnogram AND there is documentation of physical exam including airway and assessment of correctable conditions; evidence that sleep disturbance reduces quality of life/ADLs; prescription by a physician with pediatric respiratory sleep disorder expertise; documentation of the medical diagnosis causing respiratory/sleep disorder; sleep/respiratory study showing two or more objective abnormalities (oxygen saturation <90% or PaO2 <60 mmHg; CO2 >55 mmHg; apnea 10–20 seconds average of 1/hr); and a follow‑up plan including visits within the first month and within three months, a written home health follow‑up plan, and indication of a responsible, trained home environment/caregivers.

Continuous Positive Airway Pressure (CPAP) — Adults

Covered when ONE of the following adult criteria is met and OSA is documented by an attended facility-based polysomnogram or a home-based HSAT:

Adult CPAP coverage: Either AHI ≥ 15 events/hour OR AHI 5–14 events/hour with documented qualifying symptoms or comorbidities as specified in policy.see thresholds

Polysomnographic studies may be facility‑based, home, or mobile; sleep labs must be qualified Medicare/Medicaid providers and comply with state requirements.

Pediatric CPAP (Under 21)

Covered when ALL of the following pediatric criteria are met for beneficiaries under 21:

Pediatric CPAP coverage: Attended, facility‑based polysomnogram documenting OSA; documentation of physical exam including airway and of potentially correctable conditions; documentation of how sleep disturbance reduces quality of life and ADLs; prescription by a physician with pediatric respiratory sleep disorder expertise; documentation of the medical diagnosis known to cause respiratory/sleep disorders; sleep/respiratory study demonstrating two or more objective physiologic abnormalities (oxygen saturation <90% or PaO2 <60 mmHg; CO2 >55 mmHg; apnea 10–20 seconds average of one per hour); a follow‑up plan with visits within the first month and within three months; indication of a responsible, committed home environment with trained caregivers; and a written plan for home health follow‑up care.see pediatric physiologic thresholds in policy

Continuous Subcutaneous Insulin External Infusion Pumps

Covered when the beneficiary has Type I diabetes and meets Criterion A or B AND biochemical/autoantibody requirements:

Insulin pump criteria: Criterion A: Completed comprehensive diabetes education; at least six months on multiple daily injections (≥3/day) with frequent self‑adjustments; documented average glucose self‑testing ≥4 times/day during the two months prior to initiation; and meets two or more listed subcriteria (e.g., HbA1c >7.0%, recurrent hypoglycemia, wide glucose fluctuations, microvascular complications, recurrent severe hypoglycemia, suboptimal control, adolescent-specific conditions, ketosis‑prone, competitive athletes, extreme insulin sensitivity in young children). OR Criterion B: Prior pump use before Medicaid enrollment with documented average glucose self‑testing ≥4 times/day during the month prior to enrollment. In addition, the beneficiary must be insulinopenic by fasting C‑peptide ≤110% of the laboratory LLN with concurrent fasting glucose <225 mg/dL OR be autoantibody positive. The pump must be ordered and followed by a physician experienced with CSII and supported by a multidisciplinary team.Fasting C-peptide <=110% LLN with fasting glucose <225 mg/dL OR autoantibody positive

Pump ordering and follow‑up must be by qualified physician and multidisciplinary team; fasting C‑peptide only needs documentation once in the medical record.

Note: Single, manual, and hospital-grade breast pumps are not covered under Louisiana Medicaid. Louisiana Medicaid covers personal-use electric breast pumps (including double electric pumps) for nursing mothers, one new pump per viable pregnancy; coverage and device specifications for electric pumps are described elsewhere in this policy.

Medicaid will not replace equipment that is lost, destroyed, or damaged due to misuse, abuse, neglect, loss, or wrongful disposition by the beneficiary, the beneficiary’s caregiver(s), or the provider. Examples include failure to clean or maintain equipment and failure to store equipment securely. If equipment is stolen or destroyed by fire, the provider must submit a completed police or insurance report with the new prior authorization request. Replacement may be considered if the beneficiary’s medical necessity changes and appropriate documentation is provided.

Implanted devices are not covered as DME; fully implanted items are considered part of the surgical benefit rather than DME. In addition, the policy lists specific items explicitly non-covered under the DME program, including but not limited to clinically unproven or experimental equipment, comfort/convenience items, scooters, electric lifts, environmental modifications, and other items listed in the Non-Covered DME Services and Items section.

For members aged 2 years and older, ventilators are not medically necessary when they are used solely to deliver continuous or intermittent positive airway pressure (including bi-level PAP modes). The policy specifically references bi-level PAP modes and HCPCS codes E0470 and E0471 as examples of ventilator use that is not medically necessary when limited to PAP delivery; separate criteria apply when ventilators are used for neuromuscular disease, restrictive thoracic disease, or chronic respiratory failure.

Items listed under the policy’s Non-Covered DME Services and Items section are considered not reimbursable. Examples include comfort or convenience equipment, clinically unproven or investigational items, scooters, electric lifts, emergency alert devices, environmental modifications, furniture, and other explicitly listed items. Providers should not bill these items to Medicaid under the DME benefit.

Coding and Sleep Study Metrics

Ventilator/PAP-related HCPCS cited as not appropriate for ventilator useHCPCSNot Covered

E0470	Bi-level PAP, ventilator used in bi-level mode (referenced as not medically necessary when used only in bi-level PAP mode)
E0471	Bi-level PAP, ventilator used in bi-level mode (referenced as not medically necessary when used only in bi-level PAP mode)

Mechanical ventilators considered medically necessary in specified conditionsHCPCS

E0465	Trilogy mechanical ventilator (HCPCS) — referenced as considered medically necessary in certain scenarios
E0466	Trilogy mechanical ventilator (HCPCS) — referenced as considered medically necessary in certain scenarios

Cranial remolding orthosisHCPCSCovered

S1040

Cranial remolding orthosis (cranial molding helmet)

Protective helmets (safety devices)HCPCSNot Covered

A8000-A8004

Protective helmet (not cranial remolding device)

inv-22: Minimum sleep study recording

Minimum recorded sleep timeAHI must be calculated from at least two hours of actual sleep recorded without use of a positive airway pressure device; recorded hours only (no extrapolation)

Source of recordingAHI must be reported by polysomnography using actual recorded hours of sleep

ApplicabilityRequirement applies to evaluations of PAP therapy and AHI reporting for coverage decisions

inv-23: Apnea-Hypopnea Index (AHI)

Primary AHI thresholdAHI ≥ 15 events per hour

Alternate threshold with symptoms/comorbidities

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required — Clinical Criteria and Timelines

Prior authorization is required when clinical criteria must be met for coverage (for example, CPAP for adults and pediatrics and insulin pumps). Requests without prior authorization will not be approved. Emergency PA requests will be decided within two working days; non-emergency written requests will be acted on and given a decision within 25 days. All equipment needs, including emergency equipment, must be prior authorized. Unless the physician can clearly justify purchase, a rental trial of up to three months may be required to document appropriateness.

PA timelines: 2 working days for emergencies; 25 days for standard requests
Rental trial for durable equipment: up to 3 months unless physician justifies purchase
Requests without PA will not be approved

Denial Risk

Non‑Covered DME Items — Denial Risk

Device-Specific Medical Necessity Rules

Breast pump coverage and supply rules

Eligibility and timing: Covered for nursing mothers; one new pump per viable pregnancy; may be obtained at 32 weeks gestation for expectant mothers who meet criteria and intend to breastfeed.one per viable pregnancy; available from 32 weeks gestation

Device specifications: Pump must meet specified device criteria including suction limit ≤250 mmHg, adaptability for double collection, adjustable cycling rate, battery option, adjustable flange sizing, necessary accessories for simultaneous pumping, at least two BPA/DEHP‑free collection bottles, and durable materials compatible with repeated use.suction <=250 mmHg; cycling 30-60+/min

Replacement and supplies: Pump replacement allowed after >3 years and after manufacturer's warranty expiration; supplies available once every 180 days with prior authorization required.

Rental, Purchase, and Useful Lifetime Guidelines

Equipment	Rental rule / trial	Prior authorization	Notes
Durable Medical Equipment (general)	Unless physician clearly justifies purchase, a rental trial period of up to three months may be requested to document appropriateness.	All equipment needs, including emergency equipment, must be prior authorized. PAU decisions: 2 working days for emergencies; 25 days for non-emergency written requests.	Default Reasonable Useful Lifetime (RUL) for DME is 5 years; purchase vs rental decisions should consider RUL and PDAC coding guidance.

Equipment	Rental allowed	Prior authorization	Clinical requirement / Notes
Standard enteral infusion pump and accessories	Medicaid will pay for the rental of a standard enteral infusion pump and accessories.	All equipment needs must be prior authorized; rental arranged via PAU per timelines (2 working days emergency; 25 days non-emergency).	Approval requires documented evidence that syringe or gravity feedings are not satisfactory due to complications (e.g., aspiration, diarrhea, dumping syndrome).

Policy element	Rule / requirement	Operational impact	Reference
Capped rental / coding guidance	UnitedHealthcare follows PDAC for correct coding and coding clarification; PDAC guidance informs capped rental and purchase decisions.	Providers must use PDAC-validated codes; coding determines rental vs purchase pathways and reimbursement caps.	PDAC adopted as source for correct coding and coding clarification (UnitedHealthcare).
Reasonable Useful Lifetime (RUL)	Default RUL for Durable Medical Equipment is 5 years.	RUL informs expected minimum lifespan used in purchase vs rental determinations and cap considerations.	RUL defined as default minimum lifespan; starts on initial date of service.
Rental trial limit	A rental trial period of up to three months may be requested unless physician clearly justifies purchase.	Claims billed as rental should reflect trial period; PAU will process emergency and non-emergency timelines accordingly.	Rental trial guidance and PAU timelines (2 working days emergency; 25 days non-emergency).

Replacement Intervals and Limits

inv-49: electric breast pump

Replacement intervalElectric breast pump replacement allowed when pump is older than 3 years and after manufacturer's warranty expiration

Warranty considerationReplacement subject to Louisiana Medicaid DME Provider Manual Section 18.2 and manufacturer warranty status

Provider actionProviders must document age of device and warranty expiration when requesting replacement

inv-50: breast pump supplies; human milk storage bags

Supplies intervalElectric breast pump supplies available once every 180 days (prior authorization required)

Storage bags allowanceMedicaid covers 100 human milk storage bags per month; reimbursement rate covers one-month supply

Documentation Requirements and Clinical Follow-up

Documentation Required

Submit detailed device and beneficiary documentation with PA; include reports for theft/destruction replacements

Include detailed device and beneficiary information with the prior authorization request; for replacements after theft or destruction, submit supporting police or insurance reports describing the specific device.

Detailed device description and beneficiary ability to use the device
For theft/fire replacements: completed police or insurance report must accompany new PA

Documentation Required

Retain clinical and follow-up records to support medical necessity and management

Maintain clinical and follow-up documentation in the medical record to support medical necessity and ongoing management — examples include pediatric CPAP follow-up visits and insulin pump education/monitoring records.

Document follow-up visits and monitoring data (e.g., visits at 1 month and within 3 months for pediatric CPAP)
Keep diabetes education and glucose self-testing records for insulin pump candidates

Key Definitions

inv-37: Electric breast pump — Definition and coverage scope for breast pumps under Medicaid

DefinitionElectric breast pump: a mechanical device powered by batteries or electricity used by nursing mothers to extract milk

Coverage scopeMedicaid covers personal-use, double, and electric breast pumps (one new pump per viable pregnancy); available from 32 weeks gestation for expectant mothers meeting criteria

Supply and replacement rulesSupplies available every 180 days; storage bags 100 per month; replacement allowed after >3 years and post-warranty

inv-38: Ventilator not medically necessary when used only for PAP

Clinical noteFor members ≥2 years, ventilators used only to deliver continuous or intermittent positive airway pressure (including bi-level PAP modes) are not medically necessary

HCPCS examples

Non-Covered Items and Services

Not covered: Single, manual, and hospital-grade breast pumps under Louisiana Medicaid. Also not covered are ventilator use solely to deliver continuous or intermittent positive airway pressure (PAP) when such use does not meet ventilator medical necessity criteria for members ≥2 years (see PAP/ventilator section). Additionally, items listed in the Non-Covered DME Services and Items section (comfort/convenience equipment, experimental/investigational items, scooters, electric lifts, etc.) are not reimbursable.

Additional non-covered statements: the policy reiterates that fully implanted devices are not covered under the DME benefit and clarifies that Medicaid will not replace equipment lost or destroyed due to misuse, abuse, neglect, loss, or wrongful disposition. The Non-Covered DME Services and Items list includes numerous comfort, convenience, investigational, and environmental modification items that are not reimbursable.

The policy identifies a broad set of items as not covered under the DME benefit, including clinically unproven or investigational equipment, comfort or convenience equipment, scooters, electric lifts, emergency alert devices, environmental modifications, furniture, and other items listed in the Non-Covered DME Services and Items section. Fully implanted devices are excluded from DME coverage and are handled under the surgical/medical benefit.

Policy Background and Scope

Background: This Louisiana Medicaid policy defines medical necessity and coverage for Durable Medical Equipment (DME) and orthotics, aligning with federal and state requirements. It clarifies which devices and supplies are covered (for example, personal-use electric breast pumps and specified DME) and which are excluded (including implanted devices and the items listed in the Non-Covered DME Services and Items section). The policy also sets documentation, replacement, and prior authorization expectations that providers must follow.

OpenPayer

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