eviCore Durable Medical Equipment (DME) Guidelines

Covers continued rental and replacement of DME (including custom-fabricated prosthetics/orthotics), skin‑protection wheelchair cushions, Group 2 support surfaces, standing frames, and continued negative pressure wound therapy when explicit medical‑necessity criteria are met; excludes rental/replacement when criteria are unmet, when devices are repairable or under warranty, or when cushions/support surfaces are for non‑specified sites. Key requirements include re‑evaluation by the treating practitioner and documentation of continued use/benefit, device‑specific proof (e.g., failed trial of prefabricated device for custom items; prior Group 1 trial or comprehensive ulcer program and trunk/pelvis staging limits for Group 2; monthly wound measurements and physician documentation for NPWT; documented trial/tolerance, physician trained in rehab/neuromuscular evaluation, ≥12‑month daily home use expectation and patient/caregiver operability for standing frames), and supplier confirmation device cannot be repaired for replacements.