Document education and trial of device use

Education on device use must be provided to the member and/or caregiver with documented demonstrated understanding, and a trial of the requested device must be documented showing the member's demonstrated ability to use the device safely and effectively.

• Document education provided and evidence the member/caregiver demonstrated understanding.
• Document a trial of the requested device with observed safe and effective use.

Mandatory secondary review for specified complex items

All requests for specified items require mandatory secondary review by a medical director and/or therapy advisor before authorization.

• Applies to enclosed beds and other specified positioning equipment (enclosed beds require mandatory secondary review).
• Applies to custom or complex items listed elsewhere such as upper extremity/myoelectric devices and other custom O&P additions referenced in the policy.

Time-limited authorizations for WCD (initial 30 days)

Initial wearable cardioverter defibrillator (WCD) requests are authorized for 30 days when criteria are met; ongoing requests may be approved in 30-day increments up to a 90-day total with documentation of adherence and an updated plan of care.

• Initial approval: 30 days for members ≥18 meeting WCD indications.
• Continuation: 30-day increments up to 90 days contingent on adherence documentation and updated plan of care.

Secondary review required for repairs billed with K0108, K0739, E1399

Requests for wheelchair or other DME repairs billed with HCPCS codes K0108, K0739, or E1399 must undergo mandatory secondary review by a medical director or therapy advisor.

• Identify repair claims using K0108, K0739, or E1399 and submit for secondary review prior to authorization.
• Secondary review requirement is intended to evaluate repair vs. replacement and prevent overutilization.

Prior authorization removals — check current PA requirements

Certain criteria and items were removed because they no longer require prior authorization; providers should note removed items when preparing requests.

• Examples: halo procedure and equipment criteria were removed from this policy due to no prior authorization requirement.
• Review current policy code lists and prior authorization requirements before submitting requests.

Review and document applicable Medicare NCDs/LCDs/LCAs

Providers are expected to review and document the applicability of Medicare NCDs, LCDs, and Coverage Articles (as well as plan-level and state requirements) prior to requesting DME/O&P coverage, since coverage decisions are subject to those determinations.

• Document in the patient record that applicable NCDs/LCDs/LCAs were reviewed and applied when relevant.
• Coverage decisions remain subject to plan terms, state/federal requirements, and Medicare determinations for Medicare members.

Therapist/home evaluation, caregiver education, invoice, and alternatives documentation

Include a therapist evaluation and home evaluation, documentation of caregiver education, and the invoice or exact name of the requested equipment; document alternatives tried and failed.

• Therapist/occupational or physical therapy evaluation with specific functional information and home evaluation.
• Document caregiver education on proper use and the invoice/name of the bed or device requested.
• Document lower-intensity alternatives that were tried and ruled out.

Submit adherence reports and updated plan of care for WCD continuation

For ongoing WCD authorization, submit device adherence reports and a provider attestation of adherence plus an updated plan of care to support continuation beyond the initial 30 days.

• Provide objective adherence data from WCD device reports.
• Include an updated plan of care documenting ongoing need.

Document replacement medical necessity and proof of purchase; justify repairs

For replacement requests, document medical necessity and provide proof of age and date of original purchase or evidence of loss/theft/irreparable damage; for repairs, include justification and repair history.

• For replacements due to damage/theft: provide documentation supporting continued need and replacement rationale.
• For replacements based on useful lifetime: document original purchase date or demonstrate reasonable useful lifetime (e.g., manual wheelchair ≥5 years).
• For repairs: include repair justification and previous repair history.

Document trial response and screen for contraindications before pump implantation

For implantable infusion pumps, document indication, evidence of trial response (e.g., favorable intrathecal drug trial for spasticity), and screen for contraindications including allergy and active infection prior to implantation.

• Provide documentation of favorable response to a trial dose prior to implantation.
• Document absence of contraindications such as known allergy, active infection, insufficient body size, or presence of another implanted programmable device.

Provide clinical and caregiver documentation for standing frame replacements

When requesting standing frame replacements, document the clinical and caregiver criteria: height and weight requirements, that the member is alert and responsive, absence of contraindications to a standing program, and that a trained caregiver is available and able to assist safely.

• Include documentation of height and weight meeting device requirements.
• Document member alertness/responsiveness and absence of contraindications to standing.
• Document caregiver training, availability, and ability to safely assist.

Record review and applicability of NCD/LCD and plan criteria in member chart

Document in the member's record how applicable NCDs/LCDs and plan-level criteria were reviewed and applied when requesting DME/O&P coverage to ensure consistency with Medicare and plan requirements.

• Record which NCD/LCD/LCA or plan-level criteria were considered and how the member meets those criteria.
• For Medicaid members, follow state Medicaid manual provisions where they supersede this policy.