CurrentWPS Health InsurancePolicy PUM 250-0064-2503

General Durable Medical Equipment (DME) Medical Guideline

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This guideline governs general durable medical equipment (DME), including medical-necessity, ordering, documentation, delivery, continued-use, repair, replacement, and coding requirements. Coverage varies by member benefit plan and generally applies to equipment prescribed for a medical reason and primarily intended for use in the member's home.

Policy Summary

PayerWPS Health Insurance

PolicyGeneral Durable Medical Equipment (DME) Medical Guideline

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2026

Last ReviewSep 10, 2026

Next Review DateN/A

Key ActionMaintain a valid Standard Written Order or Written Order Prior to Delivery for purchases, initial rentals, order changes, and replacements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 yearsPurchase or repair/replacement limitation

6 monthsFace-to-face encounter window

12 monthsTimely continued-use documentation

5 yearsMinimum replacement interval for irreparable wear

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CurrentWPS Health InsurancePolicy PUM 250-0064-2503

General Durable Medical Equipment (DME) Medical Guideline

Customize your policy alerts

Sign up for WPS Health Insurance Policy PUM 250-0064-2503 alerts

Get alerted when Policy PUM 250-0064-2503 changes without checking for updates manually.

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Policy Summary

PayerWPS Health Insurance

PolicyGeneral Durable Medical Equipment (DME) Medical Guideline

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2026

Last ReviewSep 10, 2026

Next Review DateN/A

Key ActionMaintain a valid Standard Written Order or Written Order Prior to Delivery for purchases, initial rentals, order changes, and replacements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 yearsPurchase or repair/replacement limitation

6 monthsFace-to-face encounter window

12 monthsTimely continued-use documentation

5 yearsMinimum replacement interval for irreparable wear

60%Prosthesis replacement repair-cost threshold

Not coveredExperimental or unproven services

Durable Medical Equipment Overview

Durable medical equipment (DME) is equipment prescribed by a qualified healthcare provider for a medical reason, not typically useful to a person without a health condition, and primarily intended for use in the member’s home. Coverage under this guideline addresses general medical-necessity, ordering, documentation, delivery, continued-use, repair, replacement, and coding requirements; applicable item-specific guidelines, benefit-plan terms, and legal requirements may impose additional conditions.

General Coverage Requirements

General DME medical necessity

General DME is medically necessary and eligible for consideration when all applicable conditions are met.

General DME eligibility: The item is prescribed by a qualified treating practitioner for a medical reason; the item is not typically useful to someone without a health condition; the item is primarily intended for use in the member's home; a qualifying face-to-face encounter occurred within six months before the order; and the medical record supports the diagnosis, functional need, type, quantity, and expected use or replacement frequency.Face-to-face encounter within 6 months before prescribing

Coverage remains subject to the member's benefit plan and applicable item-specific guideline or article.

Continued medical need and use

For ongoing supplies and rented DME, continued coverage requires ongoing support unless the applicable guideline establishes that the qualifying condition is permanent.

Continued need and use: The item continues to be medically necessary and continues to be used by the member, supported by timely medical-record or supplier documentation.Timely documentation generally within the preceding 12 months

No monitoring of purchased items or capped-rental items converted to purchase is required.

Repair coverage

Repairs to member-owned DME are covered when all applicable repair conditions are met.

Member-owned DME repair: The repair is necessary to make the item serviceable; the treating practitioner documents that the item remains medically necessary; and the treating practitioner or supplier documents that the repair itself is medically necessary.No numeric threshold stated

Routine periodic maintenance and listed excluded repair categories are not separately reimbursed.

Prosthesis replacement

Replacement of a prosthesis or major component requires a new order and a documented qualifying reason.

Qualifying prosthesis replacement reason

A change in the member's physiological condition results in the need for a replacement.
Examples include changes in member weight, the residual limb, or functional need.
An irreparable change in the condition of the device or a part of the device results in the need for a replacement.
The condition of the device or part requires repairs, and the repair cost would be more than 60% of the cost of a replacement device or the part being replaced.>60% of the cost of the replacement device or component

Medical necessity

DME is medically necessary only when the applicable medical necessity condition is met.

Medical necessity: The DME is indicated by the most current medical references and specialty society guidelines, such as MCG or NCCN.

Coverage remains subject to the applicable benefit plan and professional medical judgment.

Routine periodic maintenance—including testing, cleaning, regulating, and checking—is not covered as a repair. Repairs to member-owned DME may be covered when necessary to make the item serviceable and when the applicable medical-necessity documentation requirements are met.

WPS does not separately reimburse repairs for frequent-and-substantial-servicing items, oxygen equipment, or capped-rental items during the capped-rental period. Separately billed repairs are also excluded for items covered under a manufacturer or supplier warranty and for previously denied items.

Services deemed experimental, investigational, or unproven are not covered under the clinical guidelines.

State mandates, laws, or benchmarks supersede this medical guideline. Coverage is also subject to the terms and conditions of the applicable benefit plan and applicable state and federal law.

Medical necessity must be supported by the member’s contemporaneous medical record. Supplier records, supplier-prepared statements, physician attestations, templates, or forms alone are insufficient; information submitted on a prescription must be corroborated by the medical record.

DME is not medically necessary under this guideline when it is not indicated by the most current medical references and specialty society guidelines, such as MCG or NCCN.

Coding and Billing Requirements

Correct HCPCS CodingHCPCS

HCPCS

Healthcare Common Procedure Coding System

NOC, Miscellaneous, Unlisted, or Non-specific BillingHCPCS

NOC	Not Otherwise Classified
HCPCS	Codes with narrative descriptions indicating miscellaneous, NOC, unlisted, or non-specific items or services

Prosthesis Replacement Threshold

Applies toReplacement of a prosthesis or major component, such as a foot, ankle, knee, or socket

Replacement pathwayRepair costs must exceed 60% of the cost of the replacement device or component

DocumentationA new treating practitioner's order and documentation supporting the replacement reason are required

Ordering, Documentation, and Claim Risk

Documentation Required

Standard Written Order Required

Before submitting a claim, communicate a complete Standard Written Order (SWO) to the supplier. The SWO must identify the member and ordered item and include the required practitioner information and signature.

Member's name and ID number
Order date
General description of the item, HCPCS code, HCPCS narrative, or brand name/model number; list separately billed concurrently ordered supplies
Quantity to be dispensed, when applicable
Treating practitioner's name or NPI
Treating practitioner's signature

Documentation Required

New Order and WOPD Requirements

Obtain a new order or prescription for every purchase or initial rental, when the order changes, when an item is replaced, or when a new supplier cannot obtain a valid order from the transferring supplier. A Written Order Prior to Delivery (WOPD) is a completed SWO communicated to the supplier before delivery, dated on or before delivery, and completed within six months after the required face-to-face encounter.

Key Terms

Durable Medical Equipment (DME)

Prescribing requirementPrescribed by a qualified healthcare provider for a medical reason

General usefulnessNot typically useful to someone without a health condition

Intended settingPrimarily intended for use in the member's home

Treating Practitioner

PhysicianA physician as defined in section 186(r) of the Social Security Act

Other eligible practitionersA physician assistant, nurse practitioner, or clinical nurse specialist as defined in section 1861(aa)(5) of the Social Security Act

Policy application

Medical Necessity Determination

General DME qualification

DME is considered medically necessary when the general DME and applicable item-specific requirements are met.

DME qualification: The equipment is prescribed by a qualified treating practitioner for a medical reason, is not typically useful to someone without a health condition, is primarily intended for home use, and is supported by a qualifying face-to-face encounter and member-specific medical records.Face-to-face encounter within 6 months before the order

The member's benefit plan, state or federal law, and applicable medical guideline or article may impose additional requirements.

General DME medical necessity

DME is medically necessary only when supported by current medical references and specialty society guidelines.

DME medical necessity: The equipment is indicated by the most current medical references and specialty society guidelines, such as MCG or NCCN.

Purchase and Rental Coverage Rules

Equipment category	Order requirement	Applicable rule
Purchased DME	A new order or prescription is required for all claims.	A new order is also required when the order changes, an item is replaced, or a new supplier cannot obtain a valid order from the transferring supplier.
Initial rental DME	A new order or prescription is required for all claims.	A new order is also required when the order changes, an item is replaced, or a new supplier cannot obtain a valid order from the transferring supplier.

Equipment category	Continued-use requirement	Monitoring rule
Rented DME and ongoing supplies	Documentation must support continued medical need and continued use. Acceptable documentation includes a recent practitioner order, timely medical-record usage documentation, refill records, or confirmation of continued rental use.	Suppliers must monitor utilization. Timely documentation generally means a record from the preceding 12 months, unless otherwise specified.
Purchased DME and capped-rental items converted to purchase	No ongoing monitoring of continued use is required after a capped-rental item has converted to a purchase.	Suppliers do not need to monitor utilization of purchased items or capped-rental items converted to purchase.

Replacement and Repair Intervals

DME Purchase and Repair/Replacement Limit

Benefit scopeA single purchase of a type of DME, including repair or replacement

LimitationThe benefit is limited to one purchase, repair, or replacement cycle for that type of DME every three years

Plan variationDME coverage varies across plans and remains subject to the member's benefit plan document

Replacement for Irreparable Wear

Applicable equipmentMember-owned DME, capped-rental items, and oxygen equipment

Wear-related replacementReplacement due to irreparable wear cannot occur sooner than every five years unless otherwise specified

Required Records

Documentation Required

Maintain a valid SWO or WOPD

Maintain a valid SWO for purchases, initial rentals, changes in the order, and replacements, and meet WOPD requirements when applicable. The order must include the member, date, item, quantity when applicable, treating practitioner, and signature, and must be communicated within the required timeframe.

Communicate the SWO before claim submission.
For WOPD, communicate the completed SWO before delivery; date it on or before delivery and complete it within six months after the required face-to-face encounter.

Documentation Required

Maintain current medical-record support

Maintain contemporaneous medical-record support for initial and continued medical necessity and use. Records must support the diagnosis, functional limitations, clinical course, prognosis, type and quantity of equipment, frequency of use or replacement, and ongoing use when applicable.

Timely continued-use documentation generally comes from the preceding 12 months.
Supplier records alone are not sufficient to establish medical necessity without corroboration in the contemporaneous medical record.

Excluded Services and Situations

The following are not covered or are not separately reimbursed under this guideline: routine periodic maintenance such as testing, cleaning, regulating, and checking; repairs of frequent-and-substantial-servicing items; repairs of oxygen equipment; repairs of capped-rental items during the capped-rental period; repairs of items under a manufacturer or supplier warranty; repairs of previously denied items; and services deemed experimental, investigational, or unproven. DME that does not meet applicable medical-necessity requirements is also not covered.

Policy Summary

PayerWPS Health Insurance

PolicyGeneral Durable Medical Equipment (DME) Medical Guideline

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2026

Last ReviewSep 10, 2026

Next Review DateN/A

Key ActionMaintain a valid Standard Written Order or Written Order Prior to Delivery for purchases, initial rentals, order changes, and replacements.

SourceLink

On This Page

A new order is required on a recurring basis only when specified by the applicable medical guideline.
A qualifying face-to-face encounter is required within six months before each new DME order.

Documentation Required

Medical-Record Documentation

Maintain contemporaneous medical-record support for the diagnosis, medical necessity, type and quantity of equipment, frequency of use or replacement, and applicable coding. Records may include treating-practitioner, hospital, nursing-facility, home-health, or other healthcare-professional documentation, but supplier statements, attestations, templates, and forms require corroboration.

Document the diagnosis, duration and course of the condition, prognosis, functional limitations, relevant interventions and results, and experience with related items.
Keep a sufficiently detailed description of items provided to support coding, including a narrative description, HCPCS code or long description, or brand/model number.
Reimbursement is based on utilization supported by contemporaneous medical records.

Documentation Required

Refill Documentation

For every refill, retain a record showing who requested the refill, what was requested, and an affirmative indication that the refill is needed. When billing more than one month's supply, state the number of months being billed.

Member's name or authorized representative, if different
Description of each item requested
Affirmative response confirming the need for the refill
Date of the refill request
Narrative such as “90-day supply” or “three-month supply” when applicable

Documentation Required

Proof of Delivery

For outpatient DME, make proof of delivery (POD) available on request. The date of service is the date of delivery, and the record must connect the delivered item and quantity to the member and delivery evidence.

Delivery method and member's name
Delivery address
Item description, HCPCS code or long description, or brand/model number
Quantity delivered and date delivered
Member's or designee's signature
For delivery services, package identification number, supplier invoice number, or another link to the delivery service records

Unsupported block type: documentation

Documentation Required

Repair and Replacement Records

For repairs, document that the member-owned DME remains medically necessary and that the repair itself is medically necessary. For replacements, document the qualifying loss, damage, wear, or other reason and retain the required order and supporting records.

Routine periodic maintenance, including testing, cleaning, regulating, and checking, is not covered.
WPS does not separately reimburse repairs for frequently and substantially serviced items, oxygen equipment, capped-rental items during the capped-rental period, items under a manufacturer or supplier warranty, or previously denied items.
A new treating-practitioner order is not required for ordinary repairs, but the supplier must retain detailed justification for each component or part replaced and labor time.
Replacement for irreparable wear cannot occur before five years unless otherwise specified; member-owned items, capped-rental items, and oxygen equipment may be replaced after loss or irreparable damage.
Prosthesis or major-component replacement requires a new treating-practitioner order and documentation of a qualifying physiological change, irreparable device change, or repair costs exceeding 60% of replacement cost. Retain the reason on the order or in the medical record.

Billing Rule

NOC and Miscellaneous HCPCS Billing

For any HCPCS code with a narrative indicating miscellaneous, NOC, unlisted, or non-specific billing, submit sufficient item-level and pricing information to identify and evaluate the billed service.

Description of the item or service
Manufacturer name
Product name and number
Supplier price-list amount
HCPCS code for related items, when applicable

Denial Risk

Missing Order or Qualifying Encounter

A DME claim requires a written order or prescription from the treating practitioner as a condition of payment. A qualifying face-to-face encounter must occur within six months before prescribing each new DME order, and the record must contain member-specific subjective and objective information supporting the item.

Treating practitioners include physicians, physician assistants, nurse practitioners, and clinical nurse specialists as defined in the guideline.
The encounter may be documented in the history, examination, diagnostic tests, findings, progress notes, treatment plan, or another pertinent medical-record source.
Missing the required order, face-to-face encounter, or pre-delivery communication can result in denial.

Denial Risk

Insufficient Medical-Record Support

Payment may be denied when the medical record does not substantiate the diagnosis, medical necessity, type or quantity of equipment, frequency of use, or replacement need. Supplier-created statements or a prescription alone cannot replace corroborating contemporaneous clinical records.

Records must support the member's condition, functional limitations, clinical course, prognosis, relevant treatment history, and requested utilization.
Templates, forms, and physician attestations require corroboration in the medical record.
Documentation from a supplier or another party with a financial interest is insufficient by itself to establish medical necessity.

Denial Risk

Coding and Unsupported Utilization

Code each item and service with the HCPCS code that accurately describes what was provided and retain documentation supporting the billed utilization. Incorrect coding, unsupported quantities or frequency, or utilization not supported by contemporaneous records may affect payment or result in denial.

Keep a detailed description of delivered items sufficient to validate the billed HCPCS code.
Reimbursement is limited to the specific utilization supported by contemporaneous medical records.
NOC, miscellaneous, unlisted, or non-specific HCPCS billing requires the additional item and pricing details listed in the NOC billing requirements.

Denial Risk

Excluded Repair Situations

Certain repair services are not separately reimbursed even when repair activity occurs. Screen the item and its payment category before billing and retain documentation supporting any covered repair.

No separate reimbursement for repairs to frequently and substantially serviced items, oxygen equipment, or capped-rental items during the capped-rental period
No separate reimbursement for items under a manufacturer or supplier warranty or for previously denied items
Routine periodic maintenance is not covered

Denial Risk

Experimental or Unproven Services

Services or items considered experimental, investigational, or unproven under applicable clinical guidelines are not covered. Coverage remains subject to the member's benefit plan, applicable guideline criteria, and state or federal requirements.

Use current medical references and applicable specialty-society or evidence-based guidelines when evaluating DME medical necessity.
A guideline does not itself authorize payment; verify plan benefits, exclusions, limitations, and network requirements.

The term applies throughout the guideline unless a provision specifically states otherwise

Standard Written Order (SWO)

CommunicationMust be communicated to the supplier before claim submission

Required member informationMember's name and ID number

Order detailsOrder date, general item description, and quantity to be dispensed when applicable

Practitioner informationTreating practitioner's name or NPI and signature

Description formatsMay use a general description, HCPCS code, HCPCS narrative, or brand name/model number; separately billed concurrently ordered supplies should be listed separately

Written Order Prior to Delivery (WOPD)

DefinitionA completed Standard Written Order communicated to the DME supplier before delivery

TimingThe WOPD date must be on or before the date of delivery

Face-to-face completion windowMust be completed within six months after the required face-to-face encounter

Repair Versus Replacement

RepairRestores a base DME item; replacing a part or component that makes up the base item is considered a repair

ReplacementGenerally provides an identical or nearly identical item, including for loss, theft, or irreparable damage

New accessoriesNew separately payable accessories that were not part of the initial base item are considered a replacement

State mandates, laws, or benchmarks supersede this guideline.

Replacement standard

Replacement after five years applies unless another provision of the guideline specifies otherwise

Replacement for Loss or Irreparable Damage

Applicable equipmentMember-owned DME, capped-rental items, and oxygen equipment

Qualifying eventsLoss or irreparable damage may support replacement; irreparable damage may result from a specific accident or natural disaster such as fire or flood

DocumentationThe loss or irreparable damage must be documented to support replacement

Documentation Required

Maintain refill and delivery documentation

Maintain complete refill records and outpatient proof of delivery. Refill records must document the member or authorized representative, requested items, affirmative refill need, request date, and months billed when more than one month is supplied; delivery records must document the item, quantity, date, recipient and address, delivery method, and signature or tracking evidence.

Proof of delivery must be available on request.
Use the date of delivery as the outpatient DME date of service.

Billing Rule

Complete NOC and miscellaneous HCPCS information

For NOC, miscellaneous, unlisted, or non-specific HCPCS billing, provide the item or service description, manufacturer name, product name and number, supplier price list amount, and related-item HCPCS codes when applicable.

These requirements apply when the HCPCS narrative description indicates miscellaneous, NOC, unlisted, or non-specific.