eviCore Durable Medical Equipment (DME) Guidelines

eviCore covers medically necessary DME, prosthetics, orthotics and related supplies per device‑specific HCPCS criteria but excludes investigational/experimental items (e.g., certain electrical bone growth stimulators), limits coverage for items like TENS for chronic low back pain, disallows duplicate/same-or-similar devices without justification, and denies accessories if the base DME isn’t supported. Coverage requires a pertinent clinical evaluation or meaningful technological contact with documentation of history/physical and relevant treatments, device- or condition‑specific criteria (trials of conservative therapy or device trials, home access, age/weight/MRADL limits), and strict rental/continued‑use/replacement evidence (physician re-eval, supplier repair assessment, warranty status).

"Current clinical information is necessary for determining the medical necessity of durable medical equipment, prosthetics, orthotics and supplies including all of the following: Information provide..."