eviCore Durable Medical Equipment (DME) Guidelines

eviCore covers specified DME — including continued rentals, replacements, custom‑fabricated devices, skin‑protection wheelchair cushions, Group‑2 support surfaces, standing frames, continued NPWT rental, and medically indicated cranial hair prostheses — when supported by evidence and clinical indications, while items lacking peer‑reviewed support or used for non‑medical/cosmetic reasons are considered investigational and generally not covered. Coverage requires documented treating‑practitioner re‑evaluation and specific documentation (e.g., continued medical need/use, device trial/failure or inability to use prefabricated devices for custom fabrication, monthly wound measurements and documented progress for NPWT, comprehensive ulcer care and prior Group‑1 surface trial or contraindication for Group‑2 surfaces, and listed medical causes for cranial prostheses), and replacements are limited to loss, irreparable damage, significant change in condition, supplier inability to repair, or lack of warranty.