Custom Fabricated Devices - DME.CU.101.A

Custom-fabricated DME, prosthetics, and orthotics are covered only when basic DME coverage criteria are met and a prefabricated device is inadequate (if a prefabricated device is adequate, custom fabrication is excluded). Coverage requires documentation of basic DME criteria plus one of four justifications—deformity, body habitus, need for stabilization not met by a prefabricated device, or a documented failed trial of a prefabricated device—and submission must follow DME MAC documentation rules (A55426) and applicable Medicare policy.

"Custom-fabricated equipment, prosthetics and orthotics may be indicated when basic coverage criteria have been met and there is documentation of any one of the following:"

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