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Medical Policy

Durable Medical Equipment Section

Policy Name Policy ID Number Date Modified
Bioimpedance Devices for Detection and Management of Lymphedema DME82 08/01/2022
Cooling Devices Used in the Home Setting DME07 08/01/2022
Cranial Electrostimulation Therapy (CES) DME83.06 02/01/2023

Definitive Lower Limb Prostheses

DME18 01/01/2023

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

DME75 12/01/2022

Electrical Bone Growth Stimulators (Osteogenic Stimulation)

Policy Version Effective 03/01/2023:
Electrical Bone Growth Stimulators (Osteogenic Stimulation)

DME83.11 12/01/2022
Electrical Stimulation for the Treatment of Arthritis DME83.10 09/01/2022
Electrical Stimulation for the Treatment of Wounds DME83.09


Electromagnetic Therapy DME83.13 02/01/2023
External Trigeminal Nerve Stimulation for the Treatment of Attention Deficit Hyperactivity Disorder DME83.14 05/01/2022
Functional Neuromuscular Electrical Stimulation DME83.04 04/01/2022
Galvanic Stimulation DME83.01 02/01/2023

General Medical Necessity Guidance for Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS)

DME88 12/01/2022
H-wave Stimulation DME83.02 02/01/2023

Insulin Infusion Pumps, Automated Insulin Delivery and Artificial Pancreas Device Systems

DME77 07/01/2022

Interferential Current Stimulation

DME83.07 06/01/2022
Microcurrent Stimulation (MENS) DME83.03 02/01/2023

Myoelectric Prosthetic and Orthotic Components for the Upper Limb

DME80 10/01/2022
Negative Pressure Wound Therapy in the Outpatient Setting DME42 10/01/2022

Noninvasive Ventilators in the Home Setting

DME87 10/01/2022
Oxygen Concentrators DME91 01/01/2023
Postsurgical Home Use of Limb Compression Devices DME90 01/01/2023

Power Wheelchairs: Group 3

DME37 11/01/2022

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

DME81 12/01/2022
Powered Exoskeleton for Ambulation DME89 12/01/2022
Threshold Electrical Stimulation as a Treatment of Motor Disorders DME83.05 02/01/2023

Ultrasonic Bone Growth Stimulators (Osteogenic Stimulation)

DME83.12 06/01/2022