Durable Medical Equipment (DME) Clinical Guidelines for Medical Necessity

This eviCore overview sets a prior-authorization/medical‑necessity framework for durable medical equipment (DME) that defers to the Medicare Benefit Policy Manual, NCDs/LCDs, and McKesson InterQual for covered indications and exclusions, and does not itself list item- or diagnosis-specific criteria. Providers must consult the full DME guideline and the referenced Medicare/InterQual policies for item-specific coverage, limitations, frequency rules, and required documentation and must submit documentation demonstrating medical necessity per those sources for prior authorization.

"No explicit limitations, exclusions, or frequency restrictions are provided on the supplied page."

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