EviCore Durable Medical Equipment (DME) Guidelines

EviCore covers HCPCS‑coded durable medical equipment, prosthetics, orthotics and supplies (e.g., standing frames, cranial hair prostheses, hospital beds, wheelchairs and accessories) when device‑specific medical‑necessity criteria are met, and excludes duplicative items, accessories when the base item is not covered, cosmetic‑only indications and requests that lack a documented clinical indication. Key requirements include a pertinent clinical evaluation or meaningful telehealth contact (history & physical, relevant imaging/labs, and treatment/therapy records), device trials and specialty evaluations for custom/custom‑fit or certain wheelchairs, and documentation for replacements/rental continuation (e.g., re‑evaluation, loss/theft, irreparable/out‑of‑warranty device, or changed medical condition) plus device‑specific stipulations (standing frame tolerance and 12‑month use, bed height/head‑of‑bed and weight limits, conservative therapy failure where specified).