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 |
|
Infusion pumps, implantable & external
|
Prior authorization is not required for code C2626, infusion pump, nonprogrammable, temporary (implantable)
|
| 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
11/10/09
|
