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Authorizations for Durable Medical Equipment

To request authorization for Durable Medical Equipment for a patient:

DME that requires authorization
  • You must get authorization to prescribe the purchase of any DME item of more than $1,000 ($500 for members of PriorityMedicaid plans), and all items on the list below, including all rental items.
  • Oxygen equipment: When a member's pO2 is 55 mmHg or less, he or she qualifies for oxygen and oxygen equipment without prior authorization. Priority Health may audit bi-annually to ensure compliance.

Jump down the page to rental limitations

Item requiring auth
Notes
Augmentative & alternative communications devices Get PA form (PriorityMedicaidSM patients only)
Apnea monitor Get notification form (for PriorityMedicaid patients under 21 years of age)
Prior auth not required.
Bilirubin light (after 7 days of use)
Blood pressure kit (for PriorityMedicaid)
Bone growth stimulator
Continuous Passive Motion (CPM) machine Prior auth required after 21 days
CPAP/BiPAP
Dialysis units, home

Enteral feeding pumps & supplies
Helmets, Cranial reshaping
Hospital beds See rental limits
Hoyer lifts
INR machines
Insulin pumps - ambulatory
Lymphedema compression devices - pumps/Reid sleeves (not stockings/garments)
Negative pressure wound therapy pump
(wound vac)

Neuromuscular electrical stimulators
Oral appliances (for sleep apnea only)
Orthotic shoe inserts

Oxygen therapy Get notification form (for PriorityMedicaid patients under 21 years of age)
Prior auth not required.
Orthopedic shoes
Power-operated vehicles

Prosthetics and orthotics

Pulse oximetry for home use
Prior auth required after three months
Repairs
Over $1,000 (ASO and PriorityMedicaid members, over $500)
Secretion clearing devices
(not suction pumps)
Standing frame

Strollers, adaptive
See rental limits
Support surfaces
See rental limits
Mattresses, specialty
See rental limits
Transcutaneous Electrical Nerve Stimulation (TENS)
See rental limits All codes require prior auth except: 722.52, 724.2, 724.5 and 724.6
Ultraviolet light purchase
(for specific skin conditions)
Strollers, adaptive
See rental limits
Ventilators

Wheelchair, manual  
Wheelchair, power/standing wheelchair See rental info
Wheelchair seating systems
(custom/non-custom)

Rental limitations

  • DME rental is limited to 10 months.
  • Annual maintenance authorization: Priority Health will reimburse one month's rent on the annual anniversary date of authorization for maintenance of the equipment. Authorization is still required even if the item is not used for 10 or more months.

Last modified 11/20/08