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Durable medical equipment (DME) auths

To request authorization for durable medical equipment for a patient:
  • Complete a General Prior Authorization Form (515KB PDF).
    Complete online and save it for your records, then print and fax it to Priority Health.
  • Fax the form to the number listed on the form.
Also see durable medical equipment billing information in this manual.

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 Priority Health Medicaid 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 (Priority Health Medicaid patients only)
Apnea monitor Get notification form (for Priority Health Medicaid patients under 21 years of age)
Prior auth not required
Bilirubin light (After 7 days of use authorization is required)
Blood pressure kit (For Priority Health Medicaid)
Bone growth stimulator - electric
Medical criteria must be met
Bone growth stimulator - ultrasound
Medical criteria must be met
Not covered for Priority Health Medicaid members
Continuous Passive Motion (CPM) machine Prior auth required after 21 days
Ongoing use approved for 7 days at a time
CPAP/BiPAP
Dialysis units, home

Enteral feeding pumps & supplies Pump is 10 month capped rental
Formula and supplies purchased with approval
Helmets, cranial reshaping
Hospital beds Medical criteria must be met
Allow for up to 10 month capped rental
Hoyer lifts 10 month capped rental with approval
Infusion pumps, implantable & external
Prior authorization is not required for insulin pumps – ambulatory and code C2626, infusion pump, nonprogrammable, temporary (implantable) or E0617 chemo infusion pumps.
Lymphedema compression devices - pumps/Reid sleeves E0652 - Lymphedema Pump requires prior auth - 1 month rental then convert to purchase
Reid sleeve requires PA as over $1,000 limit
Note: Stockings/garments do not require prior auth
Negative pressure wound therapy pump
(wound vac)
Medical criteria must be met
Allow up to 4 months
Neuromuscular electrical stimulators Medical criteria must be met
Oral appliances For sleep apnea only - must be contracted provider
Orthotic shoe inserts
Medical criteria must be met
Oxygen therapy Get notification form (for Priority Health Medicaid patients under 21 years of age)
Prior auth not required.
Orthopedic shoes Medical criteria must be met
Orthotics/support devices
Medical criteria must be met
Prior auth if >$500 for Medicaid
Prior auth if >$1000 for Medicare
Note: Commercial and self-funded plans do not require prior auth for knee, foot & ankle, upper extremity, and thoracic lumbar orthotics/support devices
Power-operated vehicles
Medical criteria must be met
Prosthetics and orthotics
Prior auth if >$500 for Medicaid
Prior auth if >$1000 for Commercial/Medicare/Self-Funded
Note: Orthotics/Support Devices info above
Pulse oximetry for home use
Prior auth required after three months
Repairs
Prior auth if >$500 for Medicaid
Prior auth if >$1000 for Commercial/Medicare/Self-Funded
Secretion clearing devices
Medical criteria must be met
Prior auth not required for suction pumps
Standing frame
Medical criteria must be met
Strollers, adaptive
Medical criteria must be met
Custom strollers are purchase items
Support surfaces
10 month capped rental for most
Mattresses, specialty
See rental limits
Note: Clinitron power overlay mattresses - rent by the day
Transcutaneous electrical nerve stimulation (TENS)
See rental limits
Note: The use of TENS for a two-month trial for any diagnosis does not require prior auth. For use beyond the two month trial, prior authorization is required for all codes except: 722.52, 724.2, 724.5 and 724.6
Ultraviolet light purchase
For specific skin conditions
Ventilators
Continued rental 1 unit/month
No back up ventilators allowed
Wheelchair, manual  
Wheelchair, power/standing wheelchair See rental info
For custom equipment medical criteria must be met and equipment is a purchase item
Wheelchair seating systems
(custom/non-custom)
Custom seating systems are purchase items

Rental limitations

  • DME rental is limited to 10 months. Ventilators are never capped.
  • Note: Annual maintenance authorization requires prior auth.



Last modified 06/28/10