CurrentUnitedHealthcarePolicy CS032ID.C

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

Defines applicability and guidance for medical necessity determinations, documentation, coding, and references for durable medical equipment (DME), orthotics, supplies, and repairs/replacements for UnitedHealthcare Community Plan members in Idaho.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy CS032ID.C

Change TypeMaterial revisions to documentation and reference guidance

Effective DateMay 1, 2026

Next Review Date

Key ActionProvide complete, legible medical records (history, exam, and pertinent test results) supporting medical necessity when requested.

SourceLink

POLICY UPDATE CHANGES

Replaced instruction to refer to the Idaho Medicaid Provider Handbook 'Suppliers' with referral to 'Durable Medical Equipment, Prosthetics, Orthotics, and Supplies' for medical necessity clinical coverage criteria.

Added detailed language about medical records documentation requirements to support medical necessity determinations.

Updated reference link for Electrical and Ultrasonic Bone Growth Stimulators policy title.

IdahoGeographic scope

CS032ID.CPolicy identifier

May 1, 2026

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Coverage Criteria

Delegated medical necessity criteria

Coverage determinations follow the stated order of guidance and refer to Idaho Department of Health and Welfare rules and the Idaho Medicaid Provider Handbook for clinical coverage criteria.

Governing order: Apply, in order: (1) Federal, state, and contractual requirements; (2) CMS DME MAC; (3) Related UnitedHealthcare Community Plan Medical Policies; (4) InterQual CP: Durable Medical Equipment.

Guidance order for medical necessity determinations.

Idaho references: Refer to Idaho Department of Health and Welfare Administrative Code IDAPA 16 and the Idaho Medicaid Provider Handbook, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies for medical necessity clinical coverage criteria.

Primary clinical criteria sources for Idaho policies.

This policy applies only to members and services provided in the state of Idaho, including coverage under Idaho Medicaid Plus plans. It does not apply to services or members in other states.

Medical records documentation may be required to assess whether a member meets the clinical criteria for coverage, but submission of documentation does not guarantee that the requested services will be covered. The patient’s medical record must contain legible documentation that fully supports medical necessity, including relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, and must be made available upon request.

Coding Guidance

Coding guidancemixed

No codes listed

Clinical guideline order

Primary governing order1) Federal, state, and contractual requirements

Secondary reference2) Centers for Medicare & Medicaid Services (CMS) DME Medicare Administrative Contractor (MAC)

Related UHC policies3) Related UnitedHealthcare Community Plan Medical Policies

Clinical decision support tool4) InterQual CP: Durable Medical Equipment

Provider Actions and Requirements

Prior Authorization

Coding and Prior Authorization Guidance

Prior authorization and correct coding guidance: UnitedHealthcare recognizes the CMS PDAC (Palmetto) as the authoritative source for correct DMEPOS coding and coding clarification. Providers should verify HCPCS/DMEPOS coding via PDAC prior to billing and follow the National Correct Coding Initiative. Prior authorization requirements vary by federal, state, and contractual rules; obtain any required prior authorization per the member's benefit plan before providing services.

Verify DMEPOS/HCPCS codes via PDAC (Palmetto) for accurate coding
Follow National Correct Coding Initiative guidance
Obtain required prior authorization per federal/state/contractual requirements and the member's plan

Documentation Required

Medical Record Documentation Requirements

Medical record documentation must fully support the medical necessity of the requested services. Required elements include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures. Documentation must be legible, maintained in the patient's medical record, and made available upon request.

Definitions

PDAC — Palmetto DMEPOS Administrative Contractor

PDAC designationUnitedHealthcare has established the Palmetto DMEPOS Administrative Contractor (PDAC) as a source for correct coding and coding clarification for DMEPOS.

PDAC roleManages Pricing, Data Analysis and Coding (PDAC) for Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) under CMS contract.

Coding sourceProviders should use PDAC determinations for correct DMEPOS coding and coding clarification.

Idaho-Specific Medical Necessity

Idaho-specific DME medical necessity

For specific equipment, providers must follow Idaho Administrative Code IDAPA 16 and the Idaho Medicaid Provider Handbook sections on DME, prosthetics, orthotics, and supplies.

Local rules: Clinical coverage criteria defined by the Idaho Department of Health & Welfare (IDAPA 16) and the Idaho Medicaid Provider Handbook govern determinations for durable medical equipment, prosthetics, orthotics, medical supplies, and repairs/replacements.

See IDAPA 16 and the Idaho Medicaid Provider Handbook, Durable Medical Equipment, Prosthetics, Orthotics, and Supplies.

Rental and Purchase Rules

Billing rule	Description / policy note
Rental
Per policy, DMEPOS items may be billed as rentals when consistent with federal, state, and contractual requirements and CMS guidance; PDAC coding guidance is the source for correct DMEPOS coding that informs rental vs purchase determinations.
Purchase
Items may be billed as purchases when purchase meets federal, state, and contractual coverage rules and pricing/coding determinations per CMS and PDAC indicate purchase is appropriate.
Capped rental
Capped rental rules apply as defined by CMS and applicable contractual requirements; PDAC coding clarification is used to ensure correct coding which may affect capped rental versus purchase treatment.

Replacement Policies

General DME replacement rules

ApplicabilityPolicy applies to Durable Medical Equipment, Orthotics, Medical Supplies, Prosthetics, and Repairs/Replacements for Idaho members.

Replacement determination orderApply, in order: (1) Federal, state, and contractual requirements; (2) CMS DME MAC guidance; (3) Related UHC medical policies; (4) InterQual CP: Durable Medical Equipment.

Coding influence on replacementPDAC coding and CMS/contractual rules inform whether items are billed as rental, purchase, or capped rental and can affect replacement decisions.

Documentation requirementMedical records must fully support medical necessity and be made available upon request to justify replacements.

Documentation Requirements

Documentation Required

Provide complete medical records to support necessity when requested

When requested for review, provide the complete medical record demonstrating medical necessity, including relevant history, physical exam findings, and diagnostic test results; ensure documentation is legible and available.

Relevant medical history
Physical examination findings
Results of pertinent diagnostic tests or procedures
Legible documentation maintained in the patient’s medical record and made available upon request

Not Covered / Coverage Limitations

This Medical Policy itself does not authorize services. Coverage determinations are governed by applicable federal, state, or contractual requirements; when those requirements differ from this policy, the federal, state, or contractual requirements will control. Providers should consult the applicable benefit terms before using this policy.

Background

Use Idaho-specific clinical coverage criteria when determining medical necessity for DME, orthotics, supplies, and repairs. Providers must follow the Idaho Department of Health and Welfare Administrative Code (IDAPA 16) and the Idaho Medicaid Provider Handbook sections for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies as primary clinical references. UnitedHealthcare may also use external administrative tools such as InterQual CP: Durable Medical Equipment and guidance from CMS DME MACs to assist in benefit administration.