Durable Medical Equipment (DME) reimbursement
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This policy governs reimbursement and coverage criteria for durable medical equipment, prosthetics, and orthotics for University Health Alliance members, including medical necessity, limitations, prior authorization, rental/purchase rules, and documentation requirements.
No material clinical or coverage changes in this revision.
Coverage & Medical Necessity Criteria
General Medical Necessity Criteria
Covered when ALL of the following are met:
ALL of the following
- Item meets the definition of DME, prosthetic, or orthotic (see Definitions).
- Item is used in the home (member's residence), not in a hospital or skilled/intermediate nursing facility.
- Item is ordered by the treating physician most qualified and knowledgeable about the device and its application in the individual case.
- Item is FDA approved for the purpose for which it is being prescribed.
- Criteria are met for the specific DME, orthotic, or prosthetic as stated in the pertinent UHA or referenced policies/Medicare determinations.
ALL of the following
Where no UHA-specific policy exists, medical necessity is determined using ONE of the following referenced sources:
- Hawaii Patients' Bill of Rights and Responsibilities Act (Hawaii Revised Statutes § 432E-1.4).
- Noridian Durable Medical Equipment medical necessity criteria.
- Palmetto GBA Jurisdiction 1 medical necessity criteria.
- Medicare National Coverage Determinations (NCDs).
Codes, Thresholds, and Coding Notes
| E0486 | Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment (treatment of mild OSA) |
| E0986 | Push-rim activated power assist device |
| E1231 | Pediatric wheelchair code |
| E1232 | Pediatric wheelchair code |
| E1233 | Pediatric wheelchair code |
| E1234 | Pediatric wheelchair code |
| K0004 | Adult wheelchair code |
| K0005 | Adult wheelchair code |
| K0009 | Adult wheelchair code |
| K0800 | Power mobility device (PMD) code |
| K0800-K0898 | Power mobility device (PMD) codes range |
Prior Authorization & Provider Requirements
Obtain prior authorization for enumerated DME items, repairs, purchases > $500 and rentals > $100/month
Prior authorization is required for the listed DME and related services, including The Vest™, home pulse oximeter, custom‑fabricated knee braces, custom‑fabricated prosthetics exceeding $10,000, spinal cord stimulators for pain management, insulin pumps, continuous glucose monitoring systems, oral appliance E0486 for mild OSA, custom fabricated items uniquely constructed or substantially modified, specified pediatric and adult manual wheelchairs (E1231–E1234; K0004, K0005, K0009), power mobility devices (K0800–K0898) and push‑rim activated power assist devices (E0986), any DME billed with miscellaneous HCPCS codes (E1399 and/or K0108), repairs/maintenance, purchases over $500, and rentals with total cost over $100/month.
- Prior authorization also required for repair and/or maintenance of medical equipment.
- Purchases of individual equipment or supplies costing more than $500 require prior authorization.
- Rental of equipment when total cost will be more than $100 per month requires prior authorization.
Key Definitions
Sources and Policies for Determining Medical Necessity
Sources for Medical Necessity Determination
Referenced sources for medical necessity determination
- Hawaii Revised Statutes § 432E-1.4 (Patients' Bill of Rights and Responsibilities Act).
- Noridian - Durable Medical Equipment guidance for medical necessity determinations.
- Palmetto GBA Jurisdiction 1 medical necessity criteria.
- Medicare National Coverage Determinations (NCDs).
Rental, Purchase, and Capped Rental Policies
| Item / Category | Payment Rule |
|---|---|
| DME items as categorized by Medicare (examples include manual and power wheelchairs, power mobility devices, negative pressure wound therapy, home pulse oximeters, Vest™, insulin pumps, CGM, oral appliance E0486, custom-fabricated knee braces, custom prosthetics) | |
| UHA pays either rental or purchase, whichever is most cost‑effective. Rental payments may be applied toward purchase; total rental payments may not exceed the purchase price. |
| Capped Rental Trigger | Policy Detail |
|---|---|
| Interruption in medical necessity for the same code lasting 60-plus consecutive days | |
| A new capped rental period begins after a 60-plus consecutive day interruption in medical necessity for the same code (defined as two full rental months plus remaining days in the rental month during which need ends). | |
| Change to a different code due to substantive change in condition | |
| A new capped rental period also begins for a different code when documentation shows prior condition, when prior need ended, and the new or changed condition and when the new need began; claim must include explanatory statements as listed in policy. |
Replacement and Rental Restart Rules
Documentation & Submission Requirements
Keep legible medical records proving medical necessity and provide them on request
Maintain legible medical record documentation that supports the medical necessity of the DME; records must be kept in the patient's medical record and made available to UHA upon request. UHA may perform retrospective review for items not requiring prior authorization to validate payment determinations.
- Documentation must be legible and retained in the patient’s medical record.
- Provide documentation to UHA upon request.
- Be aware UHA may conduct retrospective review for non‑PA items using the stated criteria.
Submit prior authorization requests via UHA online portal; call to establish login
Submit all prior authorization requests through UHA’s online portal. If you do not have portal login credentials, contact UHA at 808‑532‑4000 to establish access.
- Use the UHA online portal for PA requests per Administrative Guidelines.
- Call 808‑532‑4000 to establish portal login if not already set up.
Excluded Items and Limitations
The following items are not covered under this DME policy: equipment that does not meet the defined criteria for Durable Medical Equipment, orthotics, or prosthetics; items specifically excluded under the member’s plan benefits; duplicative or back-up DME intended for multiple residences or travel (for example, a back-up manual wheelchair when a power wheelchair is the member’s primary mobility device); items that provide the same medical benefit primarily for convenience without any change in the member’s condition; items that are not primarily medical in nature (such as environmental control, comfort/convenience, hygienic, exercise, or educational equipment); equipment used principally for sports, exercise, or leisure; institutional equipment used in the home; non-therapeutic or emergency/precautionary devices (including back-up equipment); and foot orthotics except when used for diabetic conditions or fractures.
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