Durable Medical Equipment and Orthotics and Prosthetics Guidelines

This policy covers durable medical equipment, orthotics, and prosthetics (e.g., burn garments, wearable cardioverter defibrillators, voice‑synthesizer blood glucose monitors for legally blind patients, and phototherapy lights) that are necessary to treat illness/injury or improve functional deficits. Coverage requires documented medical necessity, patient education and a successful trial/use, avoidance of duplicative or disproportionately costly items, device‑specific criteria (including FDA‑approved use), and limits such as WCD use only in adults ≥18 with specified high‑risk cardiac indications (initially up to 30 days with possible 30‑day renewals to a 90‑day maximum) plus numerous exclusions and equipment‑specific restrictions.

"Durable medical equipment, orthotics, and prosthetics that are necessary and reasonable for the treatment of an illness or injury or to improve the functioning of a physical deficit."