Prescription or Physician’s Written Order is required for new DMEPOS requests (see exceptions in Product Categories Guidelines). Additional clinical justification may be requested if required by CMS, Medicaid, and/or PHP guidelines:
Prescription/Physician’s Written Order with the member’s first and last name, date of birth, valid ICD-10 diagnosis code(s), ordering physician’s name and license/NPI number.
Should clearly state the item(s) name, quantity, and, if applicable, size, length of needs or number of refills.
Should be signed and dated within three months from the request date.
E-signature is accepted.
Physician’s name and date cannot be stamped if on prescription pad.
Chart or Progress Notes with the member’s first and last name, date of birth, date of encounter; ordering physician’s name and license/NPI number:
Must provide clinical justification for the requested item(s).
Must be dated within the CMS/Medicaid approved timeframe for the requested item(s).
Letter of Medical Necessity (LMN) with the member’s first and last name, date of birth, date of encounter; ordering physician’s name and license/NPI number.
Must provide clinical justification for the requested item(s).
Must be dated within the CMS/Medicaid approved timeframe for the requested item(s).
Item is being furnished by a physician or treating practitioner during an office visit where the provider determines that the brace is needed immediately due to medical necessity, or
Item is being furnished by an occupational therapist or physical therapist who determines that the brace needs to be furnished as part of a therapy session(s).
This applies to the following HCPCS codes: L0648, L0650, L1832, L1833, and L1851.
If dispensed by a DME vendor, this vendor must submit the request for a post-date authorization to DME Department shortly after the service date.
All standard requests for DMEPOS are authorized within three business days of receipt of a clean PA request.
All expedited requests for DMEPOS are authorized within 24 hours of receipt of a clean PA request.
Prescription or Physician’s Written Order should specify the type of the lift (i.e., hoyer/hydraulic, manual, power) and sling if other than the standard (i.e., with the commode opening); should have either member’s height and weight or size of the sling.
Chart notes OR Letter of Medical Necessity should justify the medical need per Medicare requirements below:
A patient lift is covered if transfer between bed and a chair, wheelchair, or commode is required and, without the use of a lift, the beneficiary would be bed confined.
Prescription or Physician’s Written Order should specify the type of bed, rails (half or full length), and required type of support surface (i.e., gel overlay or APP).
Chart notes OR Letter of Medical Necessity should justify the medical need per Medicare requirements.
General hospital bed requirements (at least one of the requirements should be met):
The beneficiary has a medical condition which requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed, or
The beneficiary requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain, or
The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration, or
The beneficiary requires traction equipment, which can only be attached to a hospital bed.
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.
Chart notes OR Letter of Medical Necessity should justify the medical need per Medicare requirements.
Air Loss Mattress is covered if the beneficiary meets at least one of the following three Criteria (1, 2 or 3):
The beneficiary has multiple stage II pressure ulcers located on the trunk or pelvis which have failed to improve over the past month, during which time the beneficiary has been on a comprehensive ulcer treatment program including each of the following:
Use of an appropriate group1 support surface, and
Regular assessment by a nurse, practitioner, or other licensed healthcare practitioner, and
Appropriate turning and positioning, and
Appropriate wound care, and
Appropriate management of moisture/incontinence, and
Nutritional assessment and intervention consistent with the overall plan of care
The beneficiary has large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis.
The beneficiary had a myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days, and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days.
Prescription or Physician’s Written Order should specify the type of the wheelchair (standard manual, lightweight, heavy-duty) and weight for heavy-duty wheelchairs.
Chart notes OR Letter of Medical Necessity should justify the medical need per Medicare requirements.
A manual wheelchair for use inside the home is covered if:
The member has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.
The member has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair, or
The member has a caregiver who is available, willing, and able to provide assistance with the wheelchair.
By signing the letter of medical necessity, the ordering physician also acknowledges that the following is true:
The residence provides adequate access between rooms for use of the manual wheelchair.
The member has not expressed an unwillingness to use the manual wheelchair that is provided in the home.
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.
Rehab (self-propelling) shower/commode chairs are defined as chairs that have large rear wheelchair style wheels, typically 18 inches or greater, to allow for self-propulsion.
Rehab style chairs are covered when the member has access to a roll in shower and is capable of independently propelling the chair into the shower and independently completing all aspects of the shower routine.
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:
The member must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features (see Documentation Requirements section). The LCMP may have no financial relationship with the supplier.
The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient.
Prescription or Physician’s Written Order should specify the type of PAP machine (e.g., CPAP, BiPAP, APAP).
Chart notes with in-person clinical evaluation by the treating practitioner prior to the sleep test to assess the member for obstructive sleep apnea.
Sleep study test ordered by the treating practitioner.
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:
Prescription or Physician’s Written Order should specify the type of PAP machine.
New sleep study is NOT required.
Required for PAP accessories:
Prescription or Physician’s Written Order for required supplies.
PAP supplies are only ordered on as needed basis for up to three months at a time. Prescribing physician should submit the request for supplies to the DME vendor.
Scripts are valid for 12 months; during this time Member can call a DME vendor requesting supplies as needed.
Prescription or Physician’s Written Order should indicate the type of oxygen therapy (i.e., Oxygen concentrator, Portable tanks, Home fill-in system, etc), oxygen saturation level, and oxygen flow rate (liter per minute).
Chart notes should justify the need for oxygen therapy and requested type including gas testing results.
CMN (Certification of Medical Necessity) form is retired on 1/1/2023.
Medicare requirements:
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:
The treating practitioner has ordered and evaluated the results of a qualifying blood gas study performed at the time of need; and,
The beneficiary's blood gas study meets Medicare criteria; and,
The qualifying blood gas study was performed by a treating practitioner or by a qualified provider or supplier of laboratory services; and,
The provision of oxygen and oxygen equipment in the home setting will improve the beneficiary’s condition.
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:
The beneficiary’s treating practitioner has contacted the IDTF to order an overnight pulse oximetry test before the test is performed.
The test is performed under the direction and/or instruction of a Medicare-approved IDTF. Because it is the beneficiary who self-administers this test, the IDTF must provide clear written instructions to the beneficiary on proper operation of the test equipment and must include access to the IDTF in order to address other concerns that may arise. The DME supplier may not create this written instruction, provide verbal instructions, answer questions from the beneficiary, apply or demonstrate the application of the testing equipment to the beneficiary, or otherwise participate in the conduct of the test.
The test unit is sealed and tamper-proof such that test results cannot be accessed by anyone other than the IDTF which is responsible for transmitting a test report to the treating practitioner. The DME supplier may use related technology to download test results from the testing unit and transmit those results to the IDTF. In no case may the DME supplier access or manipulate the test results in any form.
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:
Oxygen therapy must be recertified every 12 months.
Prescription or Physician’s Written Order should indicate the type of oxygen therapy (i.e., Oxygen concentrator, Portable tanks, Home fill-in system, etc), oxygen saturation level, and oxygen flow rate (liter per minute).
Chart notes should justify the need for oxygen therapy.
Maintenance and Oxygen Supplies:
Maintenance of the equipment such as repairs and replacement of parts is included in the monthly rental rate.
Oxygen supplies are included in the monthly rental rate and ordered on as needed basis.
Part B benefit authorized by DME. Do not call in the pharmacy:
Required:
Prescription or Physician’s Written Order should include the name of formula, dosage, method of feeding, and BMI.
Chart notes or Letter of Medical necessity that meets at least one of the coverage criteria below:
Member has inborn metabolic disorder(s).
Member has a chronic disease or medical condition complicated by rapid short-term weight loss, have a permanent structural limitation that prevents the chewing of food, and the placement of a feeding tube is medically contraindicated.
Member has a chronic disease or medical condition complicated by rapid short-term weight loss requiring supplemental nutrition and meets ONE of the following criteria:
Member has a body mass index under 18.5 as defined by the Center for Disease Control and has been in a nutrition program with documented compliance with an appropriate medical nutritional plan of care (up to 1,000 calories per day), or
Member has a body mass index under 22 as defined by the Center for Disease Control and has been in a nutrition program with documented compliance with an appropriate medical nutritional plan of care (up to 1,000 calories per day) and documented, unintentional weight loss of 5 percent or more within the previous 6-month period.
For Members with a diagnosis of HIV, AIDS, or an HIV-related illness, or other disease or condition requiring supplemental nutrition OR who have a chronic disease or medical condition complicated by rapid short term weight loss requiring supplemental nutrition, ONE of the following criteria must be met:
Member has a body mass index under 18.5 and has been in a nutrition program with documented compliance with an appropriate medical nutritional plan of care (up to 1,000 calories per day), or
Member has a body mass index under 22 and has been in a nutrition program with documented compliance with an appropriate medical nutritional plan of care (up to 1,000 calories per day) and documented, unintentional weight loss of 5 percent or more within the previous 6-month period.
CGM is a Part B pharmacy benefit that requires a prior approval from DME. Providers should submit the required paperwork to DME Department for approval. After the request is approved, Member will be able to pick up CGM supplies at the pharmacy.
Available CGM brands:
Dexcom G6 (preferred)
Abbott FreeStyle Libre (non-preferred) has a Step Therapy requirement: Participant must try and fail using Dexcom first except if Member has been using Freestyle Libre system prior to joining PHP.
Filled and signed PHP CGM request form OR Prescription with a valid ICD-10 diagnosis code and CGM system name. Note: PHP CGM request form, if filled in properly and completely, meets most of the requirements below. Chart notes may compliment the PHP CGM request form.
Chart notes justifying the medical need for CGM system:
Member has type 1, type 2, or gestational (during pregnancy) diabetes (too much sugar in your blood)
Member meets ONE of the following:
Member performs at least 4 finger-stick glucose (blood sugar) tests daily
Member is being treated with insulin and meet ONE of the following:
Member is using a continuous subcutaneous (injection under the skin) insulin infusion pump
Member uses 3 or more injections of insulin daily
Member is on an insulin treatment plan that requires frequent adjustment of insulin dosing
Member meets ALL of the following:
Member has a clinical need that cannot be managed with self-monitoring of blood glucose (such as frequent hypoglycemia [low blood sugar], hypoglycemic unawareness, unable to achieve control of diabetes)
Member has either tried (without adequate results or continuous need is identified by your doctor) or does not have access to a professional continuous glucose monitor from your doctor's office
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The State of New York has created a Participant Ombudsman Program called the Independent Consumer Advocacy Network (ICAN) to provide participants free, confidential assistance on any services offered by Partners Health Plan. ICAN may be reached toll-free at 1-844-614-8800 (TTY users call 711, then follow the prompts to dial 844-614-8800) or online at icannys.org.
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