Durable Medical Equipment (DME) Clinical Guidelines for Medical Necessity

DME items and services are covered only as defined by the Medicare Benefit Policy Manual, applicable NCDs/LCDs, eviCore DME guidelines and MCG Care Guidelines (effective 11/1/2020) and are subject to prior authorization; the excerpt does not list specific devices, frequency limits, or non‑Medicare coverage. Key requirements: prior authorization and clinical documentation demonstrating medical necessity consistent with the cited Medicare/eviCore/MCG sources are required, and applicability to non‑Medicare payers is not specified.

"DME items and services that require prior authorization under the eviCore DME Prior Authorization Criteria."

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