DMEPOS Requests & General Guidelines
Phone: (646) 455-1954 | Fax: (646) 948-1027
All DMEPOS requests require Prior Approval (PA); no verbal approval is allowed. PA is not required for Continuity of Care
General hospital bed requirements (at least one of the requirements should be met):
A variable height hospital bed is covered if the beneficiary meets one of the general requirements and requires a bed height different than a fixed height hospital bed to permit transfers to chair, wheelchair or standing position.
A semi-electric hospital bed is covered if the beneficiary meets one of the general requirements and requires frequent changes in body position and/or has an immediate need for a change in body position.
A heavy duty extra wide hospital bed is covered if the beneficiary meets one of the general requirements and the beneficiary's weight is more than 350 pounds, but does not exceed 600 pounds.
An extra heavy-duty hospital bed is covered if the beneficiary meets one of the general requirements and the beneficiary's weight exceeds 600 pounds.
A total electric hospital bed is not covered; the height adjustment feature is a convenience feature. Total electric beds will be denied as not reasonable and necessary.
Air Loss Mattress is covered if the beneficiary meets at least one of the following three Criteria (1, 2 or 3):
A manual wheelchair for use inside the home is covered if:
By signing the letter of medical necessity, the ordering physician also acknowledges that the following is true:
A heavy-duty wheelchair is covered if the member weighs more than 250 pounds or the member has severe spasticity.
An extra heavy-duty wheelchair is covered if the member weighs more than 300 pounds.
PHP allows the use of both wheelchair for longer distances and walker/rollator for inside the home.
(manual and power mobility)
All requests must be referred to the specialized clinic for custom wheelchairs/DME prior to submitting it to PHP for approval.
A positioning bath chair is covered when the documented medical and hygiene needs of the member require proper positioning and alignment while providing a stable and safe means of support during bathing. Included are all accessories required for positioning of the member such as but not limited to a head support, trunk laterals, hip laterals, pelvic belt or chest belt.
Reclining shower-commode chair is covered when recline is necessary to complete hygiene needs, and the member either has positioning needs that cannot be met by upright and a fixed angle chair or the member’s postural control requires recline.
A custom manual wheelchair is covered if, in addition to the general coverage criteria above, the specific configuration required to address the member’s physical and/or functional deficits cannot be met using one of the standard manual wheelchair bases plus an appropriate combination of wheelchair seating systems, cushions, options or accessories (prefabricated or custom fabricated), such that the individual construction of a unique individual manual wheelchair base is required.
A custom manual wheelchair is not reasonable and necessary if the expected duration of need is less than three months (e.g., post-operative recovery).
A manual wheelchair with tilt in space is covered if the member meets the general coverage criteria for a manual wheelchair above, and if criteria (1) and (2) are met:
Respiratory Equipment and Supplies
Required for initial set-up:
There is a three-month trial period after which the prescribing physician must conduct clinical re-evaluation and document that the member is benefiting from PAP therapy to continue using a PAP machine beyond the trial period. It may not require a new appointment; DME vendors usually work with the prescribing physicians directly.
Required for replacement machine:
Required for PAP accessories:
Required for initial set-up:
CMN (Certification of Medical Necessity) form is retired on 1/1/2023.
Initial coverage of home oxygen therapy and oxygen equipment is reasonable and necessary for Groups I and II if all of the following conditions are met:
Beneficiaries may self-administer home based overnight oximetry tests under the direction of a Medicare-enrolled Independent Diagnostic Testing Facility (IDTF). A DME supplier or another shipping entity may deliver a pulse oximetry test unit and related technology to a beneficiary’s home under the following circumstances:
A portable oxygen system is covered if the beneficiary is mobile within the home for Groups I and II, and the qualifying blood gas study was performed while at rest (awake) or during exercise. If the only qualifying blood gas study was performed during sleep, portable oxygen will be denied as not reasonable and necessary.
Required for Recertification:
Maintenance and Oxygen Supplies:
Custom-made Orthotics and Prosthetics
Coram is the preferred vendor.
Phone: (888) 334 -7978
Fax: (800) 693-7322
Required for initial request:
Member must call in requesting new delivery each month.
Coram re-order department phone number: (888) 334-7978.
Part B benefit authorized by DME. Do not call in the pharmacy:
Continuous Glucose Monitoring (CGM) systems
Change in order:
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