K0900 — Customized durable medical equipment, other than wheelchair
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Durable medical equipment is consideredmedically necessarywhenallof the following criteria are met:
- The requested item meets the definition of DME above;and
- The requested item has not otherwise been identified as not medically necessary or investigational and not medically necessary by a specific document;and
- There is adequate documentation in the medical records or in the claim submission ofallof the following:The documentation substantiates that the physician exercised prudent clinical judgment to order or provide this equipment for an individual for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and in accordance with generally accepted standards of medical practice. [...]
- The documentation substantiates that the physician exercised prudent clinical judgment to order or provide this equipment for an individual for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and in accordance with generally accepted standards of medical practice. [...]
- There is a clinical assessment and associated rationale for the requested DME in the home setting, as evaluated by a physician, licensed physical therapist, occupational therapist, or nurse;and
1 Active Policy
ANTHEM-CG-DME-10 — CG-DME-10 Durable Medical Equipment
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