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Medical Policy

Durable Medical Equipment Section

Policy Name   Date Modified
Bone Growth Stimulators (Osteogenic Stimulation) M-DME83.12 06/01/2023
Commode Chairs With Seat Lift Mechanism M-DME06 09/01/2023

Definitive Lower Limb Prosthesis

M-DME18 10/01/2023

Durable Medical Equipment, Prosthetic and Orthotic Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment

M-DME75 10/01/2023
Electrical Stimulation and Electromagnetic Therapy Devices M-DME83 01/01/2024
General Medical Necessity Guidance for Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS) M-DME88 01/01/2024
Gradient Compression Garments (Excluding Burn Garments) M-DME92 02/01/2024
Multi-Positional Patient Transfer System M-DME23 09/01/2023

Myoelectric Prosthetic and Orthotic Components for the Upper Limb

M-DME80 08/01/2023

Negative Pressure Wound Therapy in the Outpatient Setting

M-DME42 02/01/2024
Noninvasive Ventilators in the Home Setting M-DME87 09/01/2023
Pneumatic Compression Devices M-DME78 09/01/2023

Power Wheelchairs - Group 2 and Group 3

M-DME37 09/01/2023
Powered Exoskeleton for Ambulation M-DME89 10/01/2023

Powered and Microprocessor-Controlled Knee and Ankle-Foot Prostheses and Microprocessor-Controlled Knee-Ankle-Foot Orthoses

M-DME81 01/01/2024

Tumor Treatment Field Therapy (TTFT)

M-DME85 06/01/2023