ModifiedUnitedHealthcarePolicy BIP050.DD

Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid

Grid listing coverage stance, comments, and references for durable medical equipment, prosthetics, orthotics (non-foot) and medical supplies applicable to UnitedHealthcare plans. Governs coverage rules and cross-references to related medical policies and DME MAC LCDs.

Policy Summary

PayerUnitedHealthcare

PolicyDurable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid

Policy CodePolicy BIP050.DD

Change TypeReviseditems removedadded LCD/NCD cross-references

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionProviders must refer to the cited Medical Policies and DME MAC LCDs (for example L33789 for power mobility devices) and complete required documentation such as face-to-face exams and on-site home assessments prior to furnishing certain PMDs.

SourceLink

POLICY UPDATE CHANGES

Updated Medical Supplies Grid: renamed or consolidated multiple listed items; removed coverage guidelines for numerous items; clarified disposable items are not covered; added PMD/home assessment and battery rules; E0118 (crutch substitute) and E0144 (enclosed frame walker) called out as not covered.

~70+distinct items listed

manyitems Not Covered

multipleentries referencing LCDs/NCDs

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

3face-to-face/on-site assessment instances

20+items renamed/consolidated

Coverage Criteria and Item-Level Directives

Device-specific covered criteria

Examples of device-specific coverage with criteria references:

Continuous Passive Motion (CPM) Devices: Covered for members who have received a total knee replacement; use must commence within 2 days following surgery and is limited to the portion of the 3-week post‑op period during which the device is used at home.use begins within 2 days; limited to portion of 3 weeks

coverage limited to post‑op knee replacement use in home

Airway clearance device criteria

Cough assist coverage criteria:

Cough Assist Device/Mechanical In‑exsufflation: Covered for members who have a neuromuscular disease AND the condition causes significant impairment of chest wall and/or diaphragmatic movement resulting in inability to clear retained secretions.both criteria required

refer to DME MAC LCD L33795

Item-level coverage directives

Coverage stances and criteria pointers for listed DME items (refer to cited LCDs/NCDs and medical policies for full criteria).

Oxygen and Oxygen Equipment: Coverage = DME; coverage criteria apply; refer to the NCD for Home Use of Oxygen and DME MAC LCD L33797.

refer to NCD 240.2 and L33797

Power Mobility Devices (PMD): Coverage = DME; coverage criteria apply; face‑to‑face and home assessment requirements referenced (see L33789 and MLN SE1112).

Face‑to‑face may be required and home evaluation report must be available.

Nebulizers: Stationary and portable nebulizers covered when medically necessary for delivery of inhalation medications; large volume non‑disposable covered for specified pulmonary conditions; disposable and ultrasonic models are not covered.Only one nebulizer allowed for in‑home use; not allowed for out‑of‑home use.

refer to policy for state law exceptions (California) and clinical indications

Selected device criteria

Selected item-specific coverage rules and conditions (excerpt):

Paraffin Bath Unit (Portable): Covered when the member has undergone a successful trial period of paraffin therapy ordered by a physician and the member's condition is expected to be relieved by long‑term home use of this modality.trial period plus expectation of long‑term benefit

Standard (institutional) paraffin bath units are not covered for home use.

Traction Equipment

Traction equipment coverage distinctions:

Cervical Over‑the‑Door Traction: Covered if member has a musculoskeletal or neurologic impairment requiring traction equipment and the member was demonstrated to use and tolerate the device.demonstration and tolerance

Refer to DME MAC LCD for Cervical Traction Devices (L33823).

Cervical Attached to Headboard / Freestanding Traction Stand: Not covered when no proven clinical advantage over over‑the‑door mechanism (headboard‑attached and freestanding traction stands generally not covered).

Exceptions for specified freestanding devices when additional criteria met.

Freestanding Traction (Saunders HomeTrac style): Covered if member meets over‑the‑door criteria and one of: physician orders >20 lbs cervical traction at home; diagnosis of TMJ with prior treatment; or distortion of lower jaw/neck anatomy preventing chin halter use.>20 pounds OR TMJ with treatment OR anatomical distortion

VAC / Negative Pressure Wound Therapy

Negative Pressure Wound Therapy (VAC):

VAC devices: Covered when coverage criteria in the Negative Pressure Wound Therapy medical policy are met.see medical policy

Refer to the Negative Pressure Wound Therapy medical policy for specific indications and documentation requirements.

Mobility Assistive Equipment

Wheelchairs and power mobility:

Wheelchairs (general): Refer to Mobility Assistive Equipment policy for coverage criteria; power wheelchair Group 2/3 criteria apply for power options and rehabilitative features. Face‑to‑face and other LCD requirements may apply.face‑to‑face requirement may apply

Refer to NCD for Seat Elevation Equipment (280.16) and relevant DME MAC LCDs.

Power Mobility Device Coverage

Coverage and documentation requirements for Power Mobility Devices:

PMD coverage requirements: All of the following must be met: member meets DME coverage criteria per applicable LCD/NCD; an on‑site home assessment is performed prior to or at delivery with a written report available; battery replacement is covered only when the member purchases the device; POVs are not covered if the member is ambulatory in the home and needs a device only for outdoor movement; POVs primarily for leisure/recreation are not covered.

Refer to LCD L33789, MLN Matters SE1112, and Medicare Benefit Policy Manual Chapter 15 guidance.

Disposable Items — Not Covered

Disposable items coverage stance:

Disposable items listed are not covered (examples: diapers, disposable sheets/bags, elastic stockings, incontinence pads, irrigating kits, surgical face masks, syringes [ear bulb], wedge pillow).

Refer to referenced LCDs, NCDs, and Medicare Benefit Policy Manual sections for any exceptions or state law provisions.

General and Device-Specific Coverage Criteria

Covered when ALL of the following are met and where applicable follow the referenced NCDs/LCDs:

General medical necessity: Item is covered when it is medically necessary to treat an illness or injury and meets the DME definition; refer to the applicable NCD/LCD for item‑specific criteria.

See multiple LCD/NCD references in document

Power mobility devices: PMDs (power wheelchairs, POVs) must meet DME coverage criteria and applicable NCD/LCD requirements; on‑site home assessment and documentation required; POVs not covered for members ambulatory in‑home who only need device outside or for recreational use.

References: L33789 and related LCDs

Walkers must meet DME criteria; enclosed frame walker (E0144) lacks established medical necessity and will be denied.

Reference: L33791

Wheelchairs:

Cold therapy water-circulating pads with pumps and certain electrical stimulation/interferential devices are identified in the policy as Not Covered. These items are listed as non-covered therapies or devices and claims for them should be expected to deny unless otherwise noted in a member's evidence of coverage or a separate medical policy exception is documented.

The policy contains a long, non-exhaustive list of items considered Not Covered because they are not primarily medical in nature or are personal comfort items. Examples include air cleaners/purifiers, bathtub lifts and seats, dehumidifiers, exercise equipment, Jacuzzi, wigs/hairpieces, vehicle/trunk modifications, stair lifts, and various household comfort devices. Providers should refer to the member's EOC and applicable LCD/NCD guidance for plan-specific exclusions.

Motorized ceiling-modified lifts are listed as Not Covered because the feature is considered a convenience item and therefore does not meet the definition of DME. The policy directs providers to the Medicare Benefit Policy Manual and relevant statutes for the non-medical classification.

A broad category titled Other Non-Covered Items groups numerous personal comfort and non-medical products that are excluded from DME coverage. Representative examples call out items such as air conditioners, bed lifters, bed baths (home type), exercise equipment, whirlpool pumps, shower/bathtub seats, and telephone alert systems. These items are excluded as personal comfort or non‑DME per Medicare benefit policy references.

Specific devices explicitly identified as Not Covered include pulse oximeters (HCPCS E0445) and replacement probes (A4606), which are classified as monitoring devices and will be denied. In addition, many motorized traction/decompression devices (examples cited include VAX‑D, DRX9000, SpineMED, Lordex, DRS) are not covered; providers should refer to the Motorized Spinal Traction medical policy for details.

The policy states that Power Operated Vehicles (POVs) / scooters are Not Covered when the member is capable of ambulation within the home but requires a power vehicle only for outdoor movement, or when the device is used primarily for leisure or recreational activities. Refer to the DME MAC LCD for Power Mobility Devices (L33789) for documentation and face‑to‑face requirements.

The policy clarifies that a range of disposable items are Not Covered. Examples listed include diapers/adult incontinence garments (unless covered as a medical supply per the policy), disposable sheets and bags, elastic stockings/support hose, irrigating kits, surgical face masks, and ear‑bulb syringes. Claims for these disposable items risk denial unless a specific exception or alternate coverage category applies.

Ramps for wheelchairs, deluxe or leisure upgrades, and similar additions purchased primarily for comfort or convenience are identified as Not Covered. The policy explicitly notes that ramps and wheelchair features that serve leisure or recreational functions, or items purchased for the caregiver's convenience, do not meet DME medical necessity standards and will be excluded.

A foot drop splint/recumbent positioning device and its replacement interface will be Denied as Not Medically Necessary when prescribed for a patient with foot drop who is non‑ambulatory, since alternative treatment modalities are considered more appropriate in that clinical scenario.

The policy states that the medical necessity for an enclosed frame walker (HCPCS E0144) has not been established; consequently, furnishing an enclosed frame walker will be Denied as Not Reasonable and Necessary.

Several specific splints and mechanical stretching devices are listed as Not Covered (for example, certain static progressive stretch splints and some dental/occlusal splints per the Mechanical Stretching Devices and TMJ treatment policies). These exclusions should be cross‑referenced to the applicable medical policies cited for exact device types and coverage rationale.

The policy reiterates that a foot drop splint/recumbent positioning device and its replacement interface will be Denied as not medically necessary for a non‑ambulatory patient with foot drop, consistent with referenced AFO/KAFO guidance indicating other treatments are preferred.

The enclosed frame walker (HCPCS E0144) is emphasized as having no established medical necessity; if provided, it will be Denied as not reasonable and necessary per the walker and walkers LCD guidance.

Codes, LCD References, and Quantity Limits

Referenced LCDs and Medicare Manual sectionsmixed

No codes listed

Explicitly mentioned HCPCS codes not coveredHCPCSNot Covered

E0144	Walker with enclosed frame (not medically necessary per policy)
E0118	Crutch substitute (not covered)

Examples referencedHCPCSNot Covered

E0445	Oximeter, transcutaneous
A4606	Replacement probe for oximeter

Related LCDs for Power Mobility Devices and Wheelchair accessoriesmixed

L33789	DME MAC LCD for Power Mobility Devices
L33792	DME MAC LCD for Wheelchair Options/Accessories
L33312	DME MAC LCD for Wheelchair Seating

Oxygen and general DME reference NCD/LCDsmixed

240.2	NCD for Home Use of Oxygen
280.1	NCD for Durable Medical Equipment Reference List
L33797	DME MAC LCD for Oxygen and Oxygen Equipment

Explicit HCPCS Not CoveredHCPCSNot Covered

E0118

Crutch substitute (HCPCS) — stated as not covered due to insufficient evidence

Intermittent catheter monthly maximum referenced by LCD

Monthly maximum (Medicare LCD)Up to 200 intermittent catheters per month (Medicare maximum); prescription should reflect actual catheterization frequency—individualize to patient use.

Prescription documentationPrescription should state the actual number of daily catheterizations (e.g., 4/day ≈ 120/month).

Sterile supplies allowanceOne sterile urological catheter and one packet of lubricant are allowed for each catheterization.

Quantity limit - nebulizers

In-home nebulizer limit

Provider Requirements, Prior Authorization and Denial Risks

Prior Authorization

Prior Authorization May Be Required for PMDs

Prior authorization may be required for Power Mobility Devices (PMDs). Providers must refer to the DME MAC LCD for Power Mobility Devices (L33789) and the MLN Matters SE1112 PMD Face-to-Face Examination Checklist for specific prior auth and documentation rules before furnishing PMDs.

PMD = power wheelchairs and power operated vehicles (POVs/scooters)
Home assessment and face-to-face documentation requirements in L33789

Denial Risk

Denial Risk — Non‑Ambulatory Foot Drop Device

A foot drop splint/recumbent positioning device and replacement interface will be denied as not medically necessary when prescribed for a patient with foot drop who is non-ambulatory because other, more appropriate treatment modalities exist.

Denial applies when member is non-ambulatory and device is intended for non-ambulatory foot drop

Medical Necessity Criteria and LCD/NCD Linkage

AFO/KAFO criteria reference

Ankle‑Foot/Knee‑Ankle‑Foot Orthosis comments reference LCD criteria and include a specific exclusion:

AFO/KAFO: Coverage criteria apply; refer to DME MAC LCD L33686. Note: foot drop splint/recumbent positioning device and replacement interface will be denied as not medically necessary in non‑ambulatory patients.refer to LCD

face‑to‑face requirement may be applicable

CPM device

CPM device coverage for total knee replacement:

CPM: Use must commence within 2 days following surgery and is limited to that portion of the 3‑week period following surgery during which device is used in the member's home.<=3 weeks and start within 2 days

Rental, Purchase and Battery Replacement Rules

Item	Rule
Apnea Monitor (Infant or Child)
Rental only; documentation must include sleep study showing sleep apnea and history of apnea events. Not covered for adults.

Item	Rule
Power wheelchair / POV batteries
Battery replacement is covered only when the member owns or is purchasing (not renting) the electric wheelchair or POV; follow Medicare Benefit Policy Manual Chapter 15 §110.3 and DME MAC LCD L33792 for supplies and accessories guidance.

Item	Rule
Standard manual wheelchair
One month's rental for a standard manual wheelchair is covered if a member-owned wheelchair is being repaired; payment is made for only one wheelchair at a time and backup chairs are denied.

Item	Rule
Tracheostomy care kit (initial and replacements)
Care/cleaning starter kit covered up to 2 weeks post-operatively after open surgical tracheostomy; replacement kits covered at one per day only.

Item	Rule
Battery for electric wheelchair / POV
Purchase only — battery replacement covered when the member owns or is purchasing the device (not covered for rented equipment). See Medicare Benefit Policy Manual Chapter 15 §110.3 and DME MAC LCD L33792.

Item	Rule
Electric wheelchair / POV batteries
Battery replacement is covered only for purchased or being-purchased electric wheelchairs/POVs (not for rented devices).
Standard manual wheelchair (temporary replacement)
One month's rental for a standard manual wheelchair is covered when a member-owned wheelchair is being repaired; backup wheelchairs are denied and only one wheelchair payment is allowed at a time.

Replacement and Duplicate Equipment Rules

Wheelchairs — replacement and payment rules

Replacement ruleWheelchairs are replaced only when medically necessary; replacement due to malicious damage, neglect, or abuse is not covered.

One-wheelchair paymentPayment is made for only one wheelchair at a time; backup chairs are denied as not reasonable and necessary.

Rental during repairOne month's rental for a standard manual wheelchair is covered if a member-owned wheelchair is being repaired.

Tracheostomy care kit — initial and replacements

Initial post-op kitA tracheostomy care or cleaning starter kit is covered for up to 2 weeks post-operatively following an open surgical tracheostomy.

Replacement frequency

Required Documentation and Trials

Documentation Required

Individualized prescription and chart documentation for intermittent catheters

For intermittent catheter supplies, the chart must document the number of catheterizations per day and an individualized prescription must reflect that frequency.

Document number of catheterizations per day in the medical record
Write prescription quantities that reflect documented frequency

Documentation Required

Home assessment and face‑to‑face per referenced LCDs for PMD/PWC

Perform an on‑site home evaluation prior to or at delivery of a POV or PWC and have the written home assessment report available on request; face‑to‑face exam requirements are detailed in the referenced LCDs.

On‑site evaluation must verify maneuverability (doorway widths, thresholds, surfaces)
Written report must be available on request

Background and Scope

This grid maps commonly used DME, prosthetic, and orthotic items to coverage stances and supplies cross‑references to medical necessity criteria, applicable Medicare LCDs/NCDs, and related medical policies. It is intended to guide providers and clinical operations staff on which items meet the DME definition, which require adherence to referenced LCD/NCD criteria, and which items are excluded as personal comfort or not medically necessary.

Definitions and Term Clarifications

Aero Chamber (Spacer) — coverage note

Coverage classificationAero Chamber (spacer) is covered as DME.

California pediatric exceptionFor children under age 19, covered with mask per California law (California Health and Safety Code Section 1367.06) and via supplemental pharmacy benefit for children 3 years of age.

Use caseSpacer devices facilitate delivery of inhaled medications for asthma and other respiratory conditions when medically necessary.

Intermittent Urinary Catheters — coverage and documentation

Coverage conditionIntermittent urinary catheters are covered when basic DME coverage criteria are met and the patient or caregiver can perform the procedure.

Quantity documentation

Items and Categories Not Covered

The policy includes an extensive Not Covered list with multiple placeholder and explicit exclusions. Examples beyond those already cited include crutch substitute (E0118), POVs used only for outdoor movement when the member ambulates indoors, ramps, whirlpool pumps for non‑homebound use, and numerous household comfort items. Providers should consult the inventory within the policy for full itemization and applicable references.

An extensive list of non‑covered items is provided for items that are not primarily medical or are personal comfort items. The policy specifically enumerates many household and comfort products (e.g., air cleaners, bed lifters, Jacuzzi, shower seats, stair lifts, exercise equipment, and wigs) and instructs providers to use Medicare Benefit Policy Manual guidance and LCDs/NCDs to determine exceptions.

The policy explicitly states that the Myoelectric Arm Orthosis (MyoPro®) is Not Covered. Providers should refer to the Omnibus Codes medical policy referenced in the document for additional coding and coverage context.

The policy identifies certain nebulizer types and humidifiers as Not Covered: specifically, large volume disposable nebulizers and ultrasonic nebulizers are excluded because they offer no proven advantage or are disposable in nature; certain room or central humidifiers also are not covered as they are not DME for medical delivery of therapy.

The policy reiterates several not‑covered examples: crutch substitute (E0118) is not covered due to insufficient evidence; POVs provided only for outdoor mobility when a member ambulates indoors and POVs primarily for leisure/recreation are excluded; and enclosed frame walkers (E0144), ramps, and deluxe/leisure wheelchair upgrades are considered not medically necessary or not DME and will be denied.

Policy Changes and Revision Notes

2026-01-01nomenclature_updateLatest

Renamed and consolidated multiple items in the Medical Supplies Grid (examples: Air-Fluidized Bed, Alternating Pressure Pads and Mattress, Artificial Eye, Back Brace, Hospital Beds and Accessories, CPM devices, Cough Assist devices).

2026-01-01removal

Removed coverage guidelines for numerous items including abdominal binders, air conditioners/purifiers, bed pans, casts, incontinence pads, ramps, respiratory assist devices, traction equipment, and urinary catheter related supplies.

2026-01-01face_to_face_reference_added

Policy Summary

PayerUnitedHealthcare

PolicyDurable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid

Policy CodePolicy BIP050.DD

Change TypeReviseditems removedadded LCD/NCD cross-references

Effective DateJan 1, 2026

Next Review DateN/A

SourceLink

On This Page

Myoelectric Arm Orthosis: Coverage = Not Covered; refer to Omnibus Codes/Medical Policy for details.

item listed as not covered (MyoPro)

Refer to L33823 for details.

Only one wheelchair paid at a time; backup chairs denied; rental allowed for temporary replacement during repairs (one‑month rental for standard manual wheelchair); upgrades primarily for leisure or comfort are not covered.

Refer to L33788 and policy history

Ventilators are covered for neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure secondary to COPD; includes positive and negative pressure types.

Clinical indications per policy and NCD references

Only one nebulizer is allowed for in-home use when medically necessary; nebulizers are not allowed for out-of-home use.

Model restrictionsLarge-volume non-disposable nebulizers may be covered for specific pulmonary conditions; disposable and ultrasonic nebulizers are not covered.

DocumentationMedical necessity must be documented for stationary or portable nebulizer requests per referenced LCDs/NCDs.

Cervical traction force

Freestanding traction justificationA freestanding cervical traction device may be covered when physician orders greater than 20 pounds of cervical traction for home use.

Alternate justificationsCoverage may also be justified for TMJ with prior treatment or distortion of lower jaw/neck anatomy preventing chin halter use.

ReferenceSee DME MAC LCD for Cervical Traction Devices (L33823) for criteria and documentation requirements.

Home assessment

Required home assessmentOn-site evaluation prior to or at delivery to verify member can adequately maneuver the device considering doorway width, thresholds, and surfaces; written report must be available on request.

Who performs itSupplier or practitioner must perform the home evaluation prior to or at time of delivery of a POV or power wheelchair.

Documentation linkageRefer to DME MAC LCD for Power Mobility Devices (L33789) and MLN Matters SE1112 for face-to-face and documentation requirements.

Billing Rule

Replacement / Duplicate Wheelchair Denial and Rental Rule

Payment is made for only one wheelchair at a time. Backup or duplicate wheelchairs will be denied as not reasonable and necessary. One month's rental of a standard manual wheelchair may be allowed if a member-owned wheelchair is being repaired; repairs on rented items are the supplier's responsibility.

Only one wheelchair payment allowed at a time; backup chairs denied
One-month rental covered if member-owned wheelchair is under repair
Replacements for malicious damage, neglect, or abuse are not covered

Denial Risk

Disposable Items Not Covered

Disposable items are not covered as DME. Claims for disposable supplies (examples below) risk denial and should be billed under the appropriate benefit if covered by the member's plan.

Examples: diapers, disposable sheets and bags, elastic stockings, incontinence pads, irrigating kits, surgical face masks, syringes (ear bulb), wedge pillows
Refer to plan EOC or applicable LCD/LCA for exceptions (e.g., hospice or state law provisions)

Documentation Required

Intermittent Catheter Documentation Requirements

Intermittent urinary catheter documentation must reflect actual usage. The prescription and the member's clinical record must document the number of catheterizations per day; a chart entry is required in addition to any supplier form.

Provider should prescribe the approximate number of catheters per month based on true daily frequency (e.g., 4x/day ≈ 120/month)
Although Medicare may allow up to 200 per month in exceptional cases, ordering 200 routinely is inappropriate
One sterile catheter and one packet of lubricant allowed per catheterization

Documentation Required

Face‑to‑Face / Clinical Visit Documentation

Face-to-face documentation may be required for wheelchairs, PMDs, and certain spinal orthoses. Providers must follow the face-to-face examination requirements and complete any required documentation before submission.

Face-to-face encounter must be documented when required by the applicable LCD
Use MLN Matters PMD checklist when applicable

Documentation Required

Cervical Traction Documentation

Cervical traction devices are covered only when both the treating physician documents a musculoskeletal or neurologic impairment requiring traction and the member has demonstrated appropriate use and tolerance of the home cervical traction device.

Treating physician order and documentation of medical necessity required
Demonstration of use and tolerance must be documented

Documentation Required

Home Assessment Documentation for PMDs

A written on‑site home assessment must be performed prior to or at delivery of a POV or power wheelchair (PWC) to verify the member can safely maneuver the device within the home. The supplier or practitioner must have a written report available on request.

Home assessment must evaluate physical layout, doorway widths, thresholds, and surfaces
Written on-site evaluation report must be available upon request prior to or at delivery

Note

DME / LCD / NCD Compliance Required for PMDs and Power Wheelchairs

Prior authorization, documentation, and compliance with applicable DME MAC LCDs/NCDs is required before furnishing PMDs and certain power wheelchair groups. Providers must consult and adhere to the cited LCDs and Medicare policies to avoid denials.

Compliance with DME MAC LCDs and NCDs is required for coverage
Refer to wheelchair seating (L33312), options/accessories (L33792), and PMD documentation (L33789)

insufficient evidence for longer or other uses

DME medical necessity pointers

Item-level notes indicating when coverage applies or criteria references (detailed medical necessity criteria are in referenced LCDs/NCDs).

Intermittent Positive Pressure Breathing (IPPB): Covered if patient's ability to breathe is severely impaired; includes fluidic breathing assisters; refer to NCD Durable Medical Equipment Reference List (280.1).

refer to clinical policy and NCD

Lifts (Hoyer) / Patient Lifts: Covered when periodic movement is necessary to effect improvement or arrest deterioration; refer to NCD 280.1 and LCD L33799.

home use when clinically indicated

Nebulizers - Large Volume Non‑disposable: Covered when medically necessary to deliver humidity to members with thick tenacious secretions or specified pulmonary conditions; not for room humidification.

Only one nebulizer allowed for in‑home use when medically necessary

Paraffin bath criteria

Paraffin bath (portable)

Paraffin Bath (portable): Member must have successful trial of paraffin therapy ordered by a physician and condition expected to benefit from long‑term home use.trial completed and expectation of long‑term benefit

Standard institutional paraffin baths are not appropriate for home use and are not covered.

Freestanding traction exceptions

Freestanding cervical traction

Freestanding cervical traction coverage exceptions: Covered only if member meets over‑the‑door criteria plus one of: physician orders greater than 20 pounds for home use; TMJ diagnosis with prior treatment; or anatomical distortion preventing chin halter use.>20 lbs OR TMJ with treatment OR anatomical distortion

Refer to DME MAC LCD L33823.

General medical necessity linkage to LCD/NCD

Where applicable, coverage is contingent on meeting DME coverage criteria and referenced LCD/NCD guidance.

Apply LCD/NCD criteria: Medical necessity must be established according to the specific LCD/NCD or Medical Policy referenced for the equipment category (e.g., L33789 for PMDs, L33797 for oxygen).

Face‑to‑face and other documentation requirements may apply per the referenced LCDs.

Selected DME Medical Necessity Examples

Follow NCD/LCD referenced criteria for item-specific medical necessity (examples below).

Power wheelchair home suitability: On‑site home assessment verifies member can maneuver device in home environment (door widths, thresholds, surfaces).

Written report required

Ventilator indication: Covered for neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure due to COPD.

Includes positive and negative pressure types

Replacement tracheostomy kits are covered at a frequency of one per day only.

Reference LCDRefer to the DME MAC LCD for Tracheostomy Care Supplies (L33832).

Wheelchairs — replacement denial conditions

Replacement denial conditionsReplacement of wheelchairs is denied when due to malicious damage, neglect, or abuse.

Backup chairsBackup or duplicate wheelchairs are denied; only one wheelchair paid at a time.

Upgrades and leisure itemsWheelchair upgrades primarily for leisure or recreational activities and deluxe features are not covered.

Documentation Required

Physician order and trial evidence required for home cervical traction

Home cervical traction requires a treating physician order and evidence of a successful trial/demonstration showing the member tolerates and benefits from the device before home use.

Treating physician order documenting indication
Documentation of successful trial/demonstration and tolerance

Documentation Required

Trial and physician order required for portable paraffin bath

Portable paraffin bath requires a successful trial ordered by a physician and documentation that the member is expected to gain long‑term benefit from home use.

Documentation Required

On‑site home assessment report required for POV/PWC

An on‑site home assessment must be performed for POV/PWC and a written report must be available on request prior to or at delivery.

Documentation Required

Document catheterization frequency in the medical record

Document the number of intermittent catheterizations per day in the medical record; orders for supplies must match documented frequency to support coverage.

Documentation Required

Home assessment must document maneuverability, doorways, thresholds, surfaces

Home assessment reports for POVs/PWCs must document maneuverability including doorway widths, thresholds, and surfaces and be available on request prior to or at delivery.

Documentation Required

Face‑to‑face clinical documentation per LCD when applicable

A clinical face‑to‑face encounter may be required per the applicable LCD(s) for certain wheelchairs and spinal orthoses; follow the referenced LCD(s) for the required documentation elements.

Prescription and medical record must document the actual number of catheterizations per day; quantity supplied should reflect actual usage.

DME (Durable Medical Equipment) — definition and references

DefinitionDurable Medical Equipment (DME) is equipment that meets Medicare/benefit definitions for medically necessary durable medical equipment.

ReferencesPolicy cross-references Medicare Benefit Policy Manual chapters and applicable NCDs/LCDs for definitions, exclusions, and coverage criteria.

Examples of DMEIncludes items such as wheelchairs, oxygen equipment, power mobility devices, hospital beds, and specified therapeutic devices when criteria met.

Personal or Comfort Items — definition

DefinitionPersonal or comfort items are items not primarily medical in nature and do not meet the definition of DME.

ExamplesExamples include air cleaners/purifiers, Jacuzzi, exercise equipment, stair lifts, bed lifter, and many other home convenience items listed in policy.

Coverage stanceThese items are identified as not covered when they are personal comfort items or non-medical in nature.

VAC / Negative Pressure Wound Therapy — classification

DME classificationNegative Pressure Wound Therapy (VAC) is classified as DME when coverage criteria in the Negative Pressure Wound Therapy medical policy are met.

ReferenceRefer to the Negative Pressure Wound Therapy medical policy for specific coverage criteria and clinical indications.

Coverage noteCoverage applies only when policy criteria are satisfied; see referenced medical policy for details.

Power Mobility Device (PMD) — definition and LCD applicability

DefinitionPower Mobility Device (PMD) includes power wheelchairs and power operated vehicles (POVs or scooters); coverage is governed by DME criteria and LCDs.

Documentation requirementsDME MAC LCD L33789 and MLN Matters SE1112 outline face-to-face and home assessment documentation requirements for PMDs.

Battery replacement ruleBattery replacement for purchased PMDs is covered only when the member owns or is purchasing (not renting) the device.

Personal Comfort Items / Non-Medical DME — examples and definition

DefinitionPersonal comfort items / non-medical DME are items that are not primarily medical in nature and do not meet the DME definition.

Common examplesIncludes items such as air purifiers, Jacuzzi, exercise equipment, bed lifts, and other home convenience products listed in policy.

Coverage effectThese items are generally not covered as DME when classified as personal comfort items.

Prosthetic Devices (ostomy supplies) — classification and coverage

ClassificationOstomy bags and necessary attachments required for attachment are classified and covered as prosthetic devices.

Included suppliesCoverage includes irrigation and flushing equipment and other items directly related to ostomy care.

ReferenceRefer to Medicare Benefit Policy Manual, Chapter 15, §120 Prosthetic Devices and the DME MAC LCD for Ostomy Supplies (L33828) for coverage guidelines.

Revised multiple items to indicate DME coverage criteria apply and face-to-face requirements may be applicable (examples: Alternating Pressure Pads and Mattress, AFO/KAFO, Hospital Beds and Accessories, Knee Orthosis).

2026-01-01lcd_ncd_cross_reference_added

Added cross-references throughout to Medicare LCDs/NCDs and internal medical policies (examples: Eye Prosthesis L33737, Oxygen NCD 240.2, PMD LCD L33789).

2026-01-01disposables_clarified

Relocated and revised 'Disposable Items' language to state these items are not covered and provided examples (diapers, disposable sheets/bags, elastic stockings, incontinence pads, irrigating kits, surgical face masks, syringes, wedge pillow).

2026-01-01hcpcs_not_covered

Explicitly stated crutch substitute (HCPCS E0118) is not covered due to insufficient published clinical literature.

2026-01-01pmd_guidance_update

Updated power mobility device guidance: DME coverage criteria and LCDs apply; required on-site home assessment prior to or at delivery; battery replacement covered only for purchased equipment; POV non-coverage for members ambulatory in-home or for recreational use.

2026-01-01wheelchair_payment_rule

Clarified manual wheelchair/payment rules: payment limited to one wheelchair at a time; backup chairs denied; one-month rental allowed if member-owned wheelchair is being repaired; ramps and leisure upgrades not covered.

2026-01-01vac_language_removed

Removed language indicating Negative Pressure Wound Therapy pump was covered as DME; coverage now directed to the NPWT medical policy.

2026-01-01ventilator_coverage_replaced

Replaced ventilator coverage language to specify ventilators are covered for neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure due to COPD (includes positive and negative pressure types).