ModifiedWellCarePolicy CP.MP.107

Clinical Policy: Durable Medical Equipment and Orthotics and Prosthetics Guidelines

Customize your policy alerts

Sign up for WellCare Policy CP.MP.107 alerts

Get alerted when Policy CP.MP.107 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Governs medical necessity criteria, coding, and coverage rules for durable medical equipment (DME), orthotics, and prosthetics for WellCare members; applies to providers requesting coverage for these items. Partial policy content provided (sectioned equipment-specific criteria and HCPCS mappings).

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

ModifiedWellCarePolicy CP.MP.107

Clinical Policy: Durable Medical Equipment and Orthotics and Prosthetics Guidelines

Customize your policy alerts

Sign up for WellCare Policy CP.MP.107 alerts

Get alerted when Policy CP.MP.107 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerWellCare

PolicyDurable Medical Equipment and Orthotics and Prosthetics Guidelines

Policy CodePolicy CP.MP.107

Change TypeMultiple operational additions, removals, and clarifications

Effective Date

Next Review Date

Key ActionSubmit prior authorization with device-specific documentation (e.g., home evaluation, purchase date, repair cost comparison, and clinical justification) when requesting enclosed beds, wheelchairs, repairs, or advanced devices.

SourceLink

POLICY UPDATE CHANGES

Code E0780 added to criteria for ambulatory infusion pump.

Male vacuum erection devices changed from not medically necessary to medically necessary.

Replacement interval guidance for manual wheelchairs includes a 'reasonable useful lifetime of five years or more' for replacement consideration.

Wheelchair repair codes E1399, K0108, and K0739 added with criteria for repairs (age <5 years, repair cost < replacement, normal wear/tear).

Removed criteria and codes for flexion/extension devices (E1802, E1810, E1812) and moved them to CP.MP.144 Mechanical Stretch Devices.

Removed criteria and codes for E0466, non-invasive ventilators, and second non-invasive ventilators and moved them to CP.MP.184 Non-invasive home ventilators.

Clarified that a backup ventilator is necessary for a wheelchair-mounted ventilator if the ventilator cannot reach from the wheelchair to the bed.

Added HCPCS code E0780 to the criteria for ambulatory infusion pumps.

Removed HCPCS code Q4111 (GammaGraft) from Wound Care as it was moved to CP.MP.185 Skin Substitutes for Chronic Wounds.

Clarified E0617 is a non-wearable external defibrillator.

Nebulizer, ultrasonic: changed to not medically necessary with supporting statement.

Added criteria and codes for enclosed beds and added codes E0316, E1399 and E0328/E0329 when combined with E0316 or E1399.

Transferred diaphragmatic nerve stimulation and neuromuscular/peroneal nerve stimulator criteria to other policies (CP.MP.203 and CP.MP.48).

Replaced certain terms: 'investigational' changed to 'not proven safe and effective' in several device sections.

Added criteria for Wheelchair-mounted Assistive Robotic Arm (JACO).

Added foot orthotics (custom) criteria and codes, and added enclosed updates to prosthetics/orthotics sections (MyoPro, breast prosthetics).

Added code E0240 to 'Specialized supply or equipment' and added 'ROMTech device' criteria and coding (E1399, A9900).

Added new Lumbar-Sacral Orthotics (LSO) criteria and a long list of L-codes (e.g., L0450 through L1005) to the policy.

Updated manual wheelchair initial and replacement request criteria and deleted codes E1091 and K0009.

~100+HCPCS/L-codes added/mentioned across revisions

E0780,E0781Ambulatory infusion pump codes

L7900,L7902Vacuum erection device codes

5 yearsWheelchair useful lifetime

2-tierCriteria structure

Coverage and Medical Necessity Criteria

inv-01: General DME criteria

Covered when ALL of the following general criteria are met plus applicable equipment-specific criteria:

General criteria: 1. Education regarding use of the device, with demonstrated understanding; 2. A trial of the requested device, with demonstrated ability to use it safely and effectively.

These general requirements apply to all DME requests per policy.

inv-02: Burn garments — medical necessity

Burn garments — Covered when ALL of the following are met:

Burn garments: A. Member is at risk of a post-burn contracture; B. The garment and associated physical and/or occupational therapies are being used with the intent of preventing the need for skin grafting or contractures due to hypertrophic scarring; C. Garment is requested by the PCP and/or the treating specialist.

Associated HCPCS A6501–A6511

inv-03: Heat, cold & light therapy

Heat, cold & light therapy — examples of covered and not covered items with criteria

Ultraviolet panel lights: A. Refractory psoriasis; B. Treating physician justifies home-based phototherapy versus alternate sites (e.g., outpatient department). Panel lights should be considered when several discrete body areas can be treated individually; cabinet-style lights reserved for extensive involvement.

HCPCS E0691–E0694

Cold pad pump: Considered not medically necessary for post‑operative management because evidence does not show improved pain or edema outcomes over other conservative treatments (e.g., cold alone, compression alone).

HCPCS E0236 — may be denied

inv-04: Breast pump coverage

Breast pumps — coverage limits and purchase/rental rules

Breast pumps: A. Medically necessary for a breastfeeding member when the benefit is covered in the member's state; B. Purchase allowed when cost is $250 or less; C. If cost exceeds $250, approve as rental up to the purchase price then convert to purchase; D. Limit one per member when benefit applies.$250

HCPCS E0604

inv-05: Enclosed beds — medical necessity

Enclosed beds — require therapy/medical review and multiple criteria

Enclosed beds: A. Standard bed or hospital bed is unable to meet positioning needs due to the member's disability; B. Less intensive alternatives (e.g., bed rails, mattress on floor, removal of hazards, bed alarms, video/audio monitors, environmental/behavioral interventions, physician‑directed medications) have been tried and ruled out with documentation; C. Medical diagnosis such as cerebral palsy, developmental delay, or genetic/neurological disorder causing disorientation or uncontrolled movement; D. Healthcare provider evaluation (typically PT/OT) including specific functional status and home evaluation; E. Name of and invoice for the bed or enclosure requested.

Requests reviewed by medical director/therapy advisor; HCPCS E0316, E1399, and E0328/E0329 (when combined)

inv-06: Orthotics & Prosthetics — necessity and replacement

Orthotics and prosthetics — device-specific criteria and replacement rules

Lumbar‑sacral orthotics (LSO): Medically necessary when ordered for vertebral compression fracture; scoliosis meeting progression/curve thresholds; status‑post spinal surgery; muscular dystrophy; or ALS. Requests for OA/DJD require secondary review.See policy thresholds (e.g., curve increased >5 degrees in 6 months; curve ≥30° with Risser 0–2 or Sanders <6)

HCPCS L0200, L0450 and expanded L‑code list

Custom cervical collar: Requests reviewed by a licensed PT/OT; documentation must state why prefabricated collars are inadequate.

HCPCS L0170, L0190, L0200

Custom foot orthotics: Medically necessary for arch/heel/other foot pain when BOTH: (1) at least one qualifying condition is present (e.g., diplegic cerebral palsy, juvenile idiopathic arthritis, pes cavus, rheumatoid arthritis, plantar fasciitis with symptoms ≥3 months, posterior tibial tendon dysfunction); AND (2) documentation that activity modification, medications, prefabricated orthotics, physical therapy, and stretching have failed.

inv-07: Explicit NMN items

Not medically necessary items explicitly listed

Explicitly not medically necessary: MyoPro® orthosis is considered not medically necessary due to insufficient evidence to support use over alternatives.

HCPCS L8701, L8702

inv-08: Pumps and implantable infusion devices

Infusion and pump devices — indications and criteria

Ambulatory infusion pump indications: Medically necessary when used for: (A) acute iron poisoning (deferoxamine); (B) chemotherapy for unresectable primary hepatocellular carcinoma or colorectal metastases limited to the liver or patient refuses resection; (C) opioid administration for intractable cancer pain; OR (D) to administer a drug requiring prolonged infusion ≥8 hours for improved efficacy OR intermittent infusions <8 hours when both: (1) no return to physician's office is required prior to each infusion; and (2) a strictly controlled infusion rate is necessary due to toxicity concerns.Prolonged infusion ≥ 8 hours (or specified intermittent criteria)

HCPCS E0780, E0781

Gastric suction and implantable infusion pumps: Home gastric suction pumps and implantable infusion pumps are medically necessary when clinical indications are met (e.g., inability to empty gastric secretions; specific hepatic chemotherapy or intrathecal antispasmodic indications).

HCPCS E2000, E0782, E0783, E0785, E0786

Parenteral pump for medication administration:

inv-09: General and device-specific medical necessity

Covered when ALL of the following general and equipment-specific criteria are met:

General DME criteria: Equipment is prescribed by a physician; meets the definition of DME; is necessary and reasonable for treatment of an illness or injury; primarily for use in the home. Documentation must demonstrate education and a successful trial where applicable.

Applies to all equipment types

Ambulatory infusion pump indications: Pump use meets one of the specific indications: iron poisoning (deferoxamine), specified hepatic/colorectal chemotherapy uses, opioid delivery for intractable cancer pain, prolonged infusion ≥8 hours for improved efficacy, or intermittent infusions <8 hours meeting both subcriteria (no return to office and strictly controlled infusion rate required).

HCPCS E0780, E0781

Vacuum erection device (VED): VED and tension ring are medically necessary for erectile dysfunction when prescribed by a physician and less invasive therapies have been tried as applicable.

HCPCS L7900, L7902

inv-10: Wheelchair repair

Wheelchair repair coverage

Repair criteria: Requests for wheelchair repairs using codes K0108, K0739, or E1399 are medically necessary when: (A) the wheelchair is less than 5 years old (document purchase date); (B) cost of repairs is less than replacement cost; (C) repairs result from normal wear and tear rather than abuse/misuse or overutilization.

One month's rental for a standard manual wheelchair is considered medically necessary if the member's owned wheelchair is being repaired.

inv-11: Policy reorganization and coverage stance updates

Policy-level coverage actions and reorganizations documented in these chunks include:

Moved criteria: Detailed criteria for several device categories were removed from this policy and transferred to specialized policies (e.g., flexion/extension devices to CP.MP.144; non‑invasive ventilators to CP.MP.184; skin substitutes to CP.MP.185; neuromuscular stimulation to CP.MP.48).

Providers must consult the referenced policies for full criteria.

Added device sections: New or updated sections were added for ambulatory infusion pumps (E0780), enclosed beds (E0316/E1399 ± E0328/E0329), ROMTech device (E1399, A9900), Wheelchair‑mounted Assistive Robotic Arm (JACO), MyoPro orthosis (L8701/L8702), and expanded Lumbar‑Sacral Orthotics L‑codes.

Each new/updated section contains device‑specific criteria elsewhere in the policy.

Effectiveness and stance changes: Some device effectiveness stances changed (e.g., ultrasonic nebulizers changed to not medically necessary; intrapulmonary percussive ventilation effectiveness not supported). These changes affect coverage determinations.

Refer to updated device sections for impact on claims.

The policy identifies several items as not medically necessary when available evidence or intended use do not support coverage. Examples include the non-wearable external defibrillator with integrated ECG (E0617), which is considered primarily a safety device and therefore not medically necessary, and non-pneumatic compression devices (K1032, K1033), for which the policy states there is insufficient clinical evidence to support safety and effectiveness compared with standard pneumatic devices. The policy also lists devices that lack sufficient published evidence of clinical benefit—e.g., the MyoPro orthosis (L8701, L8702)—and treats them as not medically necessary based on current literature review.

Providers should use these specific exclusions when assessing coverage: if a requested item is listed as not medically necessary in the policy (per the HCPCS/L-code references above), coverage is not supported under the policy criteria and may be denied unless other applicable plan documents or state/Medicare rules override this stance.

The policy explicitly classifies certain respiratory and hydrotherapy devices as not medically necessary. Ultrasonic nebulizers (E0575) are stated to provide no clinical advantage over small-volume nebulizers and compressors and therefore are not medically necessary. Similarly, whirlpool tubs (E1310) are listed as not medically necessary. Requests for these HCPCS codes should be evaluated as non-covered per the policy unless superseded by state Medicaid provisions or Medicare NCD/LCDs.

The policy revises prior language and indicates that certain uses of pneumatic compression devices are not proven safe and effective. Specifically, pneumatic compression devices are not proven safe/effective for lymphedema involving the abdomen, trunk, chest, genitals, or neck, and are not supported for use in the presence of arterial insufficiency. This revised stance replaces prior terminology such as 'investigational' and should guide coverage determinations for these anatomic sites and conditions.

When a conflict exists between this clinical policy and state Medicaid coverage provisions, the state Medicaid provisions take precedence and must be followed. Additionally, when Medicare National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs) apply, those Medicare rules must be reviewed and govern coverage decisions where applicable. Coverage decisions remain subject to the member's evidence of coverage and applicable Health Plan administrative policies.

HCPCS / L-code / CPT Mappings

Burn garments HCPCSHCPCSCovered

A6501	Burn garments HCPCS (listed)
A6511	Burn garments HCPCS (listed)

Cardiac equipment HCPCSHCPCSNot Covered

E0617

Non-wearable external defibrillator with integrated ECG

Compression therapy HCPCSHCPCSNot Covered

K1032	Non-pneumatic compression device
K1033	Non-pneumatic compression device

Diabetes care equipment HCPCSHCPCSCovered

E2100

Blood glucose monitor with integrated voice synthesizer

Heat, cold & light therapy HCPCSHCPCSCovered

E0691	Ultraviolet panel light
E0692	Ultraviolet panel light
E0693	Ultraviolet panel light
E0694	Ultraviolet panel light

Cold pad pump HCPCSHCPCSNot Covered

E0236

Cold pad pump

Newborn care equipment HCPCSHCPCSCovered

E0604

Breast pump

Enclosed beds and related HCPCSHCPCS

E0316	Enclosed bed HCPCS
E1399	Other DME, HCPCS not otherwise specified
E0328	Enclosed bed HCPCS (variant)
E0329	Enclosed bed HCPCS (variant)

Orthotics and prosthetics HCPCS (selected list)HCPCS

E0849	Cervical traction equipment
L0170	Cervical collar, custom molded
L0200	Lumbar-sacral orthotic HCPCS
L0450	Lumbar-sacral orthotic component HCPCS
L0490	Hip orthotics HCPCS (listed among many)
L1700	Legg Perthes orthotics HCPCS
L3000	Custom foot orthotic HCPCS
L3904	Shoulder/elbow/wrist/hand orthotic HCPCS
L5990	Prosthetics and additions: Lower extremity
L6000	Upper extremity prosthetic HCPCS

1–10 of 12

1/2

Pumps and infusion devices HCPCSHCPCS

E0780	Ambulatory infusion pump
E0781	Ambulatory infusion pump
E2000	Gastric suction pump HCPCS
E0782	Gastric suction pump HCPCS
E0783	Implantable infusion HCPCS
E0785	Implantable infusion HCPCS
E0786	Implantable infusion HCPCS
K0455	Parenteral pump HCPCS
L7900	Parenteral pump / vacuum erection device HCPCS
L7902	Vacuum erection device HCPCS

Ambulatory infusion pump HCPCSHCPCSCovered

E0780	Ambulatory infusion pump
E0781	Ambulatory infusion pump

Gastric suction pump HCPCSHCPCSCovered

E2000	Gastric suction pump
E0782	Gastric suction pump (home model)

Implantable infusion pump HCPCSHCPCSCovered

E0783	Implantable infusion
E0785	Implantable infusion
E0786	Implantable infusion

Parenteral pump and VED HCPCSHCPCSCovered

K0455	Parenteral pump for medication administration
L7900	Vacuum erection device

Nebulizer HCPCSHCPCSNot Covered

E0575

Ultrasonic nebulizer (not medically necessary)

IPPB & suppliesHCPCSCovered

E0500	IPPB device
E0550	IPPB supplies

OximeterHCPCSCovered

E0445

Oximeter (monitoring/alarm device)

Standard walker codesHCPCSCovered

E0130	Standard walker
E0135	Standard walker
E0141	Standard walker
E0143	Standard walker

Heavy duty / special walker codesHCPCSCovered

E0148	Heavy duty walker
E0149	Heavy duty walker
E0147	Variable wheel resistance walker (multiple braking)

Wheelchair and components HCPCSHCPCSCovered

E1086	Manual/power wheelchair related HCPCS (list)
E2300	Power seat elevator on power wheelchair

Whirlpool tubHCPCSNot Covered

E1310

Whirlpool tub

Repair / unlisted codesHCPCSCovered

K0108	Wheelchair repair
K0739	Wheelchair repair
E1399	Unlisted DME — used in this policy for repairs/other items

Highlighted HCPCS codes (added/removed/moved)HCPCS

E0617	Non-wearable external defibrillator
E0780	Ambulatory infusion pump (added to criteria)
E1802	Flexion/extension device (moved to CP.MP.144)
E1810	Flexion/extension device (moved to CP.MP.144)
E1812	Flexion/extension device (moved to CP.MP.144)
E0466	Non-invasive ventilator (criteria moved to CP.MP.184)

Other Equipment / miscellaneous codesHCPCS

E0240	Specialized supply or equipment (added to Other Equipment)
E1399	Unspecified respiratory/other device (used for ROMTech, intrapulmonary percussion noted as not supported)
A9900	Miscellaneous DME supply (used with ROMTech)

New/updated L-codes and prosthetics codesHCPCSCovered

L0450	LSO (Lumbar-Sacral Orthosis) code (one of many L-codes added)
L1005	LSO / spinal orthotic related code (listed among many)
L8701	MyoPro Orthosis
L8702	MyoPro Orthosis
L8030	Breast prosthesis
L8035	Breast prosthesis (listed)

Removed from Wound CareHCPCSNot Covered

Q4111

GammaGraft (moved to CP.MP.185)

inv-45: Lumbar-sacral orthotic scoliosis progression

Progression definitionCurve increased by more than 5 degrees within 6 months

Clinical contextUsed to determine medical necessity for Lumbar‑Sacral Orthotics (LSO) when scoliosis is progressive

Prior Authorization, Documentation, and Provider Responsibilities

Prior Authorization

Medical director/therapy review required

Requests for enclosed beds, complex prosthetics, and many prosthetic/orthotic items must be reviewed by a medical director and/or therapy advisor to determine medical necessity.

Applies to enclosed beds (HCPCS E0316, E1399, E0328/E0329) and to requests for upper- and lower-extremity/myoelectric prosthetics that meet specified criteria.

Prior Authorization

Wheelchair prior authorization

Initial requests for manual and power wheelchairs require documentation that criteria are met, including mobility limitations that cannot be met with a cane or walker, expected improvement in MRADLs, adequate home access, and willingness/ability of user or caregiver to use the wheelchair.

Include applicable HCPCS (e.g., E1050–E1130) when submitting prior authorization.
Replacement requests require documentation supporting loss/theft/irreparable damage or meeting the reasonable useful lifetime threshold of five years plus continued need.

Device-Specific Medical Necessity Rules

inv-75: General DME criteria (medical necessity section duplicate for decision trees)

Covered when ALL of the following general criteria are met plus applicable equipment-specific criteria:

General criteria: 1. Education regarding use of the device, with demonstrated understanding; 2. A trial of the requested device, with demonstrated ability to use it safely and effectively.

Core general DME medical necessity requirements.

inv-76: Breast pump medical necessity and acquisition rules

Breast pump medical necessity and acquisition rules

Breast pump rules: A. Covered for breastfeeding members when covered by state benefit; B. Purchase allowed if cost ≤ $250; C. If cost > $250, approve as rental up to purchase price then convert to purchase; D. Limit one per member when benefit applies.$250

HCPCS E0604. Policy language updated for inclusivity.

Acquisition Rules: Rental vs Purchase

Item	Rule
Breast pump (HCPCS E0604)
Purchase if cost ≤ $250; if cost > $250 approve as rental up to purchase price then convert to purchase; limit one per member when benefit applies in the state.

Item	Rule
Enclosed bed (HCPCS E0316, E1399, E0328/E0329 when combined)
Requests reviewed by a medical director and/or therapy advisor; purchase when approved. Medical necessity requires: (A) standard bed/hospital bed unable to meet positioning needs due to disability; (B) less intensive alternatives tried and ruled out with documentation; (C) qualifying medical diagnosis (e.g., cerebral palsy, developmental delay, genetic/neurological disorders causing disorientation/uncontrolled movement); (D) healthcare provider evaluation including functional status and home evaluation; (E) name and invoice for bed requested.

Item

Rule

Enclosed bed (HCPCS E0316, E1399, E0328/E0329 when combined)

Requests reviewed by a medical director and/or therapy advisor; purchase when approved. Medical necessity requires: (A) standard bed/hospital bed unable to meet positioning needs due to disability; (B) less intensive alternatives tried and ruled out with documentation; (C) qualifying medical diagnosis (e.g., cerebral palsy, developmental delay, genetic/neurological disorders causing disorientation/uncontrolled movement); (D) healthcare provider evaluation including functional status and home evaluation; (E) name and invoice for bed requested.

Item	Rental rule / Notes
Standard manual wheelchair
One month's rental for a standard manual wheelchair is considered medically necessary if the member's owned wheelchair is unusable while repairs are performed; repair requests using K0108, K0739, or E1399 require documentation and review.

Item	Rental rule / Notes
Standard manual wheelchair
One month's rental for a standard manual wheelchair is considered medically necessary if a member/enrollee's owned wheelchair is being repaired; replacement and repair documentation requirements and replacement intervals (useful lifetime ≥5 years) apply per policy updates.

Replacement Intervals and Useful Lifetime

inv-86: Orthotics and prosthetics replacement notes

Replacement guidance summaryOrthotics and prosthetics replacement considered when device no longer functions, has irreparable wear, significant physiologic change, or repair cost >60% of replacement cost

Therapist reviewMany prosthetic/orthotic replacement requests are reviewed by a licensed physical or occupational therapist

Normal wear-and-tear replacementReplacement due to normal wear-and-tear is considered medically necessary when the orthotic/prosthetic remains needed and is a lateral purchase per contract guidelines

inv-87: Manual wheelchair useful lifetime (5 years)

Useful lifetime for manual wheelchairs>= 5 years (reasonable useful lifetime)

Repair age limit reference

Required Documentation

Documentation Required

Provide device-specific clinical and administrative documentation

Provide clinical and administrative documentation as specified for each device type (examples: enclosed beds require home evaluation and caregiver education; prosthetics require clinical exam findings and a rehabilitation plan; replacement requests require evidence of irreparable damage or physiologic change).

Documentation Required

Document age, repair cost vs replacement, and justification for repair/replacement

For repairs, document the purchase date/age (repairs are covered when the wheelchair is <5 years old), show repair cost is less than replacement cost, and provide justification for replacement or repair (loss/theft/irreparable damage or ongoing need).

Include invoice/purchase date and a repair versus replacement cost comparison.

Documentation Required

Background and Scope

Durable medical equipment supports members with illness or injury by providing items that are durable, primarily used for a medical purpose, and necessary and reasonable for treatment in the home setting. Orthotics are devices designed to support, protect, or restrict motion of a body part, while prosthetics replace a body part or function following limb loss or congenital conditions. The policy requires that general DME criteria—education with demonstrated understanding and a trial showing safe, effective use—be met in addition to any device-specific criteria before coverage is approved.

This background establishes the framework for coverage decisions: equipment must be prescribed by a physician, appropriate for the member’s medical condition, and supported by documentation consistent with accepted standards of medical practice.

Key Definitions

inv-68: Durable Medical Equipment (DME) definition

Definition (concise)Durable medical equipment (DME): Equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, and is generally not useful in the absence of illness or injury.

Durability noteItems considered durable can normally be rented; expendable medical supplies are not considered durable (e.g., incontinence pads, catheters)

Prescription requirementDME is equipment prescribed by a physician and necessary and reasonable for treatment of an illness or injury

inv-69: Orthotic device definition

DefinitionOrthotic device: Rigid and semi‑rigid devices used to support a weak or deformed body part or to restrict or eliminate motion in a diseased or injured body part.

Examples

Items Considered Not Medically Necessary

Not covered items called out across the policy include several device examples and broader stances. Highlighted exclusions include the non-wearable external defibrillator (E0617), certain compression devices lacking evidence (K1032, K1033), the cold pad pump (E0236) for post-operative management, the MyoPro orthosis (L8701, L8702) as lacking sufficient evidence, ultrasonic nebulizers (E0575), and whirlpool tubs (E1310). Intrapulmonary percussive ventilation (noted under E1399) is also identified as unsupported by current evidence. These entries should be used to screen requests for noncovered items.

Where items are specifically listed as not covered or not medically necessary, providers should document clinical rationale and consider alternate covered therapies. Absent documentation meeting criteria or applicable overriding rules (e.g., state Medicaid or Medicare NCD/LCD), requests for these items should be denied in accordance with the policy’s exclusions and medical necessity determinations.

Policy Summary

PayerWellCare

PolicyDurable Medical Equipment and Orthotics and Prosthetics Guidelines

Policy CodePolicy CP.MP.107

Change TypeMultiple operational additions, removals, and clarifications

Effective Date

Next Review Date

SourceLink

On This Page

Plantar fasciitis symptoms ≥ 3 months

Prosthetic replacement: Replacement allowed when: current prosthesis no longer functions or has irreparable wear; significant physiologic or surgical change in residual limb; repair cost exceeds 60% of replacement cost; prosthesis properly cared for per manufacturer's recommendations; continued functional benefit and updated order/documentation provided.Repair cost > 60% of replacement cost

Reviewed by licensed PT/OT; HCPCS L5990 and related codes

Medically necessary when uninterrupted parenteral administration is required and less invasive therapy failed (including a 6‑week trial); pump must be FDA‑approved for the drug/purpose and no contraindications to implantation exist.

6‑week trial of noninvasive methods

Oximeter use indications: Oximeter (E0445) is medically necessary when used as a monitoring/alarm device for: home ventilator or tracheostomy patients; determining home oxygen needs; weaning from home oxygen; or monitoring an unstable respiratory condition. Not indicated for routine monitoring of stable conditions or asthma management.

Walker criteria: Standard walker is medically necessary when MRADLs in the home cannot be met due to mobility limitation, the walker can be safely used, and the functional mobility deficit will be sufficiently resolved with a walker. Heavy duty or special walkers meet the standard criteria plus weight (>300 lb) or inability to use a standard walker due to severe neurologic disorder/one‑hand restriction.

HCPCS E0130/E0135/E0141/E0143 (standard); E0148/E0149/E0147 (heavy/special)

Manual wheelchair initial and replacement criteria: Initial manual wheelchair is medically necessary when mobility limitations interfere with MRADLs and cannot be met with a cane/walker; the wheelchair will significantly improve MRADLs; home access is adequate; user/caregiver willing and able to use; and caregiver assistance or safe self‑propulsion is available. Replacement is medically necessary for loss/theft/irreparable damage with documentation of continued need and like‑for‑like replacement, OR after a reasonable useful lifetime (≥5 years) or change in status requiring different equipment with documented continued need.Reasonable useful lifetime ≥ 5 years for replacement consideration

HCPCS lists included for manual wheelchairs

Wheelchair criteria updates: Manual wheelchair initial and replacement criteria were reformatted and updated; standing frame criteria reorganized with pediatric age thresholds added. Wheelchair repair rental guidance (one month's rental) was added.

Replacement guidance includes reasonable useful lifetime of five years or more where applicable.

Associated codesLSO section includes multiple L‑codes (see policy for L0450–L1005)

inv-46: Lumbar-sacral orthotic initial curve size

Initial curve thresholdCurve ≥ 30 degrees when first diagnosed with a Risser level of 0–2 or Sanders classification < 6

Use for LSO eligibilityMeets one of the scoliosis indications for Lumbar‑Sacral Orthotics (LSO)

Relation to progression ruleApplied alongside progression criteria (e.g., >5° in 6 months) for coverage determinations

inv-47: Repair cost threshold for prosthesis replacement

Repair vs replacement thresholdRepair cost greater than 60% of replacement cost triggers replacement consideration

Documentation requiredMedical documentation must show irreparable wear or that repair cost exceeds threshold

Review processReplacement requests reviewed by licensed physical/occupational therapist as part of prosthetics replacement criteria

inv-48: Wheelchair useful lifetime

Useful lifetime standard>= 5 years (reasonable useful lifetime)

Replacement due to lifetimeReplacement may be considered after reasonable useful lifetime of five years or more with documentation of continued need

Alternate reasons for replacementLoss, theft, or irreparable damage with documentation also permit replacement regardless of age

inv-49: Age thresholds for standing frames initial requests

Pediatric standing frame — developmental delayInitial requests under 18: developmental delay in ambulation and ≥ 18 months of age

Pediatric standing frame — neuromuscular impairmentInitial requests under 18: documented neurological or neuromuscular impairment and ≥ 1 year of age

Documentation needsRequests must include documentation supporting height/weight, developmental status, and caregiver training/availability

Prior Authorization

Updated code/prior authorization note

Certain device requests now reference added or moved HCPCS/L-codes (for example, E0780 for ambulatory infusion pumps and new L-codes for LSOs); providers should follow the revised criteria and related policy when submitting prior authorization.

Code E0780 was added to ambulatory infusion pump criteria.
New L-codes for lumbar‑sacral orthotics were added and manual wheelchair criteria were reformatted.

Note

Prior authorization and coverage guidance

This clinical policy provides medical necessity guidance to assist coverage decisions, but prior authorization requirements are governed by the Health Plan's administrative policies and applicable state and Medicare rules and should be verified before submission.

Coverage decisions are subject to member benefit terms, state Medicaid provisions, and Medicare NCDs/LCDs where applicable.

Denial Risk

Wheelchair replacement documentation

Replacement requests lacking documentation of continued medical necessity or not meeting the useful lifetime (≥5 years) or loss/theft/irreparable damage criteria may be denied.

Ensure documentation shows continued mobility limitation and reasons for replacement (loss/theft/irreparable damage or ≥5‑year useful lifetime).

Step Therapy

Trials required before advanced devices

For certain advanced devices (e.g., parenteral pumps, vacuum erection devices), document trials of less invasive therapies and that they were ineffective—parenteral pump candidacy requires a 6‑week trial of noninvasive methods.

Parenteral pump (K0455) and VED (L7900/L7902) criteria require evidence of failed noninvasive therapy (6‑week trial).

Documentation Required

Required documentation and evaluation

Provide documentation of education and demonstrated understanding and evidence of a trial showing the member can use the requested device safely and effectively.

General requirement for all DME: education and a successful trial prior to coverage determination.
Enclosed beds additionally require home evaluation and therapist assessment of functional status.

Documentation Required

Wheelchair repair documentation

When requesting wheelchair repairs, include purchase date/age to show the wheelchair is <5 years old, a cost-comparison showing repair cost is less than replacement, and documentation that damage is due to normal wear and tear rather than abuse or misuse.

Repair codes include K0108, K0739, and E1399; one month's rental for a standard manual wheelchair is considered medically necessary if the owned wheelchair is unusable.

Documentation Required

Documentation aligns with standards

Providers should maintain documentation consistent with generally accepted standards of medical practice and evidence-based guidelines; this policy is a guide to medical necessity and not a guarantee of payment.

Documentation must comply with Health Plan, state, and Medicare requirements where applicable.

Denial Risk

Cost-comparison denial

A higher cost item will be denied if a medically necessary, lesser cost item exists that will meet the member's needs—confirm lower-cost alternatives have been considered and documented.

This cost‑comparison rule applies across DME categories when a lower-cost medically necessary item is available.

Denial Risk

Cold pad pump denial

Cold pad pump (HCPCS E0236) is considered not medically necessary for post‑operative management and may be denied; do not submit E0236 for postoperative cold/edema management expecting coverage.

Policy text: "Cold pad pump... Considered not medically necessary for post-operative management."

Documentation Required

Wheelchair replacement documentation

Replacement requests for manual wheelchairs must document continued medical necessity and meet criteria for loss/theft/irreparable damage or demonstrate the device has reached a reasonable useful lifetime (≥5 years) or the member's status has changed requiring different equipment.

Replacement must be for same or similar equipment when for loss/theft/irreparable damage, or after ≥5 years with documentation of continued mobility limitation and other initial criteria.

Note

Removed/migrated codes

Do not rely on codes or criteria that were removed from this policy (for example E1802, E1810, E1812, E0466); if items reference moved codes, follow the destination policy (e.g., CP.MP.144, CP.MP.184) when seeking coverage or authorization.

Requests referencing removed/migrated codes may trigger denial or referral until evaluated under the correct target policy.

Note

Coverage decision constraints

Coverage decisions are subject to the member's coverage documents, state Medicaid provisions, Medicare NCDs/LCDs, and Health Plan administrative policies; verify applicable benefit and regulatory rules prior to authorization submission.

When state Medicaid provisions conflict with this policy, state manuals take precedence; Medicare NCDs/LCDs must be reviewed where applicable.

inv-77: Prosthetic replacement

Prosthetic replacement

Prosthetic replacement: Replacement requests require documentation that the current prosthesis no longer functions properly, has irreparable wear, or there has been a significant physiologic/surgical change to the residual limb; repair cost exceeds 60% of replacement cost; device has been properly cared for; continued functional benefit is documented and an updated order is provided when required.Repair cost > 60% of replacement cost

Reviewed by licensed PT/OT; HCPCS L5990 and related codes

inv-78: Ambulatory and implantable infusion pump indications

Ambulatory and implantable infusion pump indications

Ambulatory infusion pump indications: Medically necessary when used for: (A) deferoxamine administration for acute iron poisoning; (B) hepatic or colorectal chemotherapy indications where disease is unresectable or patient refuses resection; (C) opioid delivery for intractable cancer pain; OR (D) administration of drugs requiring prolonged infusion ≥8 hours or intermittent infusions <8 hours meeting both subcriteria (no return to physician's office required prior to each infusion AND strictly controlled infusion rate necessary due to toxicity concerns).Prolonged infusion ≥ 8 hours or specified intermittent criteria

HCPCS E0780, E0781 (E0780 added per revision).

Implantable infusion pump indications: Implantable infusion pumps are medically necessary for specified indications (e.g., hepatic chemotherapy, intrathecal antispasmodic therapy) when clinical criteria are met and there are no contraindications to implantation.

HCPCS E0783, E0785, E0786

inv-79: Walker criteria

Walker criteria

Standard walker: MRADLs in the home cannot be met due to mobility limitation; walker can be safely used by the member; functional mobility deficit will be sufficiently resolved with a walker.

HCPCS E0130, E0135, E0141, E0143

Heavy duty / special walker: Meets standard walker criteria plus member weight >300 lb or inability to use a standard walker due to severe neurologic disorder or one‑hand restriction (variable wheel resistance/multiple braking).

HCPCS E0148, E0149, E0147

inv-80: Wheelchair criteria and repair/replacement

Wheelchair criteria and repair/replacement

Initial manual wheelchair: Mobility limitation interferes with MRADLs that cannot be met with a cane or walker; manual wheelchair will significantly improve MRADLs; home provides adequate access and maneuvering space; member or caregiver willing to use the wheelchair; and either caregiver assistance or safe self‑propulsion is available.

HCPCS lists for manual and power wheelchairs

Replacement is medically necessary when: (A) due to loss, theft, or irreparable damage with documentation of continued need and like‑for‑like replacement; OR (B) after a reasonable useful lifetime (≥5 years) or change in status requiring different equipment with growth features maximized and continued need documented.Reasonable useful lifetime ≥ 5 years

Documentation required to demonstrate continued medical necessity

Repair coverage: Repairs using K0108, K0739 or E1399 are medically necessary when wheelchair is <5 years old (purchase date documented), repair cost is less than replacement cost, and need for repair is due to normal wear and tear rather than abuse/misuse. One month's rental for a standard manual wheelchair is medically necessary while owned wheelchair is being repaired.

HCPCS K0108, K0739, E1399

inv-81: Selected DME medical necessity examples

Examples of documented criteria updates (full decision trees are in other parts of the policy):

Standing frame initial request (pediatrics): For initial requests in members <18 years, in addition to general criteria, require one of: (A) developmental delay in ambulation and ≥18 months of age; OR (B) documented neurological/neuromuscular impairment and ≥1 year of age. Documentation must support height/weight and caregiver availability/training.

See standing frame section for full criteria.

Wheelchair rental during repair: One month's rental for a standard manual wheelchair is considered medically necessary if a member's owned wheelchair is being repaired.

Added to wheelchair repair criteria.

Repairs considered medically necessary when wheelchair is less than 5 years old (documented purchase date)

Replacement documentationReplacement requires documentation of continued medical necessity and like‑for‑like replacement when due to loss/theft/irreparable damage

inv-88: Manual wheelchairs, standing frames (replacement rules)

Replacement rule alignmentReplacement requests for manual wheelchairs and standing frames must meet updated replacement criteria and may require that replacement meet initial request criteria as reformatted

Pediatric standing frame replacementReplacement requests must also meet existing criteria required for initial request, including developmental/age thresholds and documentation

Code and criteria updatesManual wheelchair section reformatted and some pediatric wheelchair codes removed; providers should follow revised criteria and updated HCPCS lists

Detailed clinical and functional documentation per updated criteria

Submit detailed clinical and functional documentation that meets the updated criteria for initial and replacement requests (for example, standing frames and manual wheelchairs require documentation of age, developmental status for pediatrics, height/weight, caregiver availability/training, and functional needs).

For pediatric standing frames, include developmental milestones and age thresholds where required.

Documentation Required

Maintain documentation consistent with plan and regulatory requirements

Maintain documentation supporting medical necessity consistent with the Health Plan's requirements and generally accepted standards of medical practice; providers remain responsible for clinical judgment and member care.

Includes braces and other supportive orthotic components described in the policy

Replacement contextReplacement due to normal wear-and-tear considered per contract guidelines when device remains medically necessary

inv-70: Prosthetic device definition

DefinitionProsthetic device: Custom-made artificial limbs or assistive devices that replace a body part or function due to trauma, vascular disease, diabetes, cancer, or congenital disorders.

Replacement criteriaReplacement allowed when prosthesis no longer functions, has irreparable wear, physiologic change, or repair cost >60% of replacement cost, with supporting documentation

Rehabilitation requirementComprehensive prosthetic rehabilitation plan required (pre-prosthetic training, functional task training, home exercise, follow-up plan)

inv-71: Durable medical equipment (alternate excerpt)

Alternate DME phrasingDME: Equipment prescribed by a physician, durable (withstands repeated use), primarily used for medical purposes in the home, and necessary and reasonable for treatment of illness or injury.

Place-of-service implicationSome institutions may not be considered a member's home (e.g., hospitals, skilled nursing facilities) for rental/purchase rules

Clinical documentationCertain DME may require additional documentation to determine whether item constitutes medical equipment (e.g., new market items)

inv-72: Member/Enrollee's home definition

Home definitionMember/Enrollee's home: dwelling, apartment, relative's home, home for the aged, or other institution unless the institution meets hospital or skilled nursing facility definitions; permanent admission to SNF/hospice makes that facility the member's home.

Rental/purchase relevanceDefinition used to determine applicability of rental and purchase rules for DME

Exclusion examplesInstitutions primarily engaged in inpatient physician‑supervised care or skilled nursing are not considered the member's home for policy purposes

inv-73: E0617 — non-wearable external defibrillator

HCPCS code & descriptionE0617 — Non‑wearable external defibrillator

Coverage stanceNoted in document as a non‑wearable external defibrillator; listed among cardiac equipment updates

Policy contextReferenced in policy revisions and moved/clarified in updates to device sections

inv-74: ROMTech/PortableConnect device reference

Device referenceROMTech/PortableConnect device referenced under 'Other Equipment' with coding guidance (E1399, A9900)

Coding notePolicy added coding and criteria for ROMTech device and listed E1399 and A9900 as applicable codes

ContextIncluded as part of Other Equipment / telerehabilitation device updates