Durable Medical Equipment (DME) General Criteria - DME.AD.100.A

DME is covered only when it provides therapeutic benefit and is primarily medical in purpose (non‑medical/comfort items are excluded), duplicates are not allowed, accessories are denied if the base item isn’t covered, and limits apply for rental/purchase and reasonable useful lifetime (typically 3–5 years). Key requirements: a treating practitioner (physician, PA, NP, or CNS) must prescribe the item and document medical necessity with a face‑to‑face encounter within 6–12 months, a Standard Written Order (SWO), a clinical evaluation, proof of delivery or WOPD when applicable, and peer‑reviewed literature support when the item does not meet the DME definition.

"DME is indicated when all of the following are met:"

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