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UnitedHealthcare? Community Plan
Coverage Determination Guideline
Durable Medical Equipment, Orthotics, Medical Supplies,
and Repairs/Replacements (for North Carolina Only)
Guideline Number: CSNC.CDG.009.02
Effective Date: April 1, 2022 Instructions for Use
Table of Contents Page Related Policies
Application ..................................................................2 ? Attended Polysomnography for Evaluation of Sleep Disorders
Coverage Rationale ....................................................2 (for North Carolina Only)
Definitions ...................................................................3 ? Beds and Mattresses (for North Carolina Only)
Applicable Codes .......................................................5 ? Cochlear Implants (for North Carolina Only)
References ..................................................................5
Guideline History/Revision Information ....................6 ? Continuous Glucose Monitoring and Insulin Delivery for
Instructions for Use ....................................................6 Managing Diabetes (for North Carolina Only)
? Electrical and Ultrasound Bone Growth Stimulators (for North
Carolina Only)
? Electrical Stimulation for the Treatment of Pain and Muscle
Rehabilitation
? Hearing Aids and Bone Anchored Hearing Aids (for North
Carolina Only)
? Home Traction Therapy (for North Carolina Only)
? Manual Wheelchairs (for North Carolina Only)
? Mechanical Stretching Devices
? Motorized Spinal Traction
? Obstructive and Central Sleep Apnea Treatment (for North
Carolina Only)
? Omnibus Codes (for North Carolina Only)
? Patient Lifts (for North Carolina Only)
? Pediatric Gait Trainers, Standing Systems and Walkers (for
North Carolina Only)
? Plagiocephaly and Craniosynostosis Treatment (for North
Carolina Only)
? Pneumatic Compression Devices (for North Carolina Only)
? Power Mobility Devices (for North Carolina Only)
? Speech Generating Devices (for North Carolina Only)
? Transcutaneous Electrical Nerve Joint Stimulators (for North
Carolina Only)
? Wheelchair Options and Accessories (for North Carolina Only)
? Wheelchair Seating (for North Carolina Only)
Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for North Carolina Only) Page 1 of 2
UnitedHealthcare Community Plan Coverage Determination Guideline Effective 04/01/2022
Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc.
Application
This Coverage Determination Guideline only applies to the state of North Carolina.
Coverage Rationale
Indications for Coverage
Durable Medical Equipment (DME) is a Covered Health Care Service when the member has a DME benefit, the equipment
is ordered by a physician to treat an injury or sickness (illness), and the equipment is not otherwise excluded in the
member benefit plan document. DME must be:
? Not consumable or disposable except as needed for the effective use of covered DME;
? Not of use to a person in the absences of a disease or disability;
? Ordered or provided by a physician for outpatient use primarily in a home setting; and
? Used for medical purposes
Contact Lenses & Scleral Bandages (Shells)
Contact lenses or scleral shells that are used to treat an injury or disease (e.g., corneal abrasion, keratoconus, or severe dry
eye) are not considered DME and may be covered as a therapeutic service. In these situations, contact lenses and scleral shells
are not subject to a plan's contact lens exclusion.
Implanted Devices
Any device, appliance, pump, machine, stimulator, or monitor that is fully implanted into the body is not covered as DME.
Note: If covered, the device is covered as part of the surgical service.
Note for cochlear implant benefit clarification: The replacement external components (i.e., speech processor, microphone,
and transmitter coil) are considered under the DME benefit. The initial implantable and external components are considered
under the medical-surgical benefit. The member specific benefit plan document must be referenced to determine if there are
DME benefits for repair or replacement of external components.
Lymphedema Stockings for the Arm
Post-mastectomy lymphedema stockings for the arm are considered DME. For state specific information on mandated
coverage, refer to the state or contractual requirements.
Medical Supplies
? Medical Supplies that are used with covered DME are covered when the supply is necessary for the effective use of the
item/device (e.g., oxygen tubing or mask, batteries for power wheelchairs and prosthetics, or tubing for a delivery pump).
? Ostomy Supplies are limited to the following:
o Irrigation sleeves, bags, and ostomy irrigation catheters
o Pouches, face plates and belts
o Skin barriers
Note: Benefits are not available for deodorants, filters, lubricants, tape, appliance cleaners, adhesive, adhesive remover, or
other items not listed above (check the member specific benefit plan document for coverage of ostomy supplies).
? Urinary Catheters:
o Benefits for indwelling and intermittent urine catheters for incontinence or retention
o Benefits include related urologic supplies for indwelling catheters limited to:
Urinary drainage bag and insertion tray (kit)
Anchoring device
Irrigation tubing set
o Documentation should include the number and type of catheters that are needed.
Note:
? Certain plans may exclude coverage for Urinary Catheters (e.g., test, drug, device, or procedure). Refer to the member
specific benefit plan document to determine if this exclusion applies.
Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for North Carolina Only) Page 2 of 3
UnitedHealthcare Community Plan Coverage Determination Guideline Effective 04/01/2022
Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc.
? For additional supply information, refer to the Coverage Limitations and Exclusions section.
Orthotic Braces
Orthotic braces that stabilize an injured body part and braces to treat curvature of the spine are considered DME (refer to the
Coverage Limitations and Exclusions). Examples of orthotic braces include but are not limited to:
? Ankle Foot Orthotic (AFO)
? Knee orthotics (KO)
? Lumbar-sacral orthotic (LSO)
? Necessary adjustments to shoes to accommodate braces
? Thoracic-lumbar-sacral orthotic (TLSO)
Note: There are specific codes that are defined by HCPCS as orthotics that UnitedHealthcare covers as DME.
Pleurx Bottles and Tubing
Pleurx bottles and tubing are covered as DME.
Trachea-Esophageal and Voice Aid Prosthetics
Trachea-esophageal prosthetics and voice aid prosthetics are covered as DME.
Ventilators and Respiratory Assist Devices applies for 2 years of age and older
Ventilators and Respiratory Assist Devices are covered under certain circumstances. For medical necessity clinical coverage
criteria, refer to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy for Medical Equipment, 5A-2
Respiratory Equipment and Supplies.
Medical Necessity Plans
In the absence of a related policy or coverage indication from above, UnitedHealthcare uses available criteria from the DME
MAC.
DME, related supplies, and orthotics are Medically Necessary when:
Ordered by a physician; and
The item(s) meets the plans Medically Necessary definition (refer to the member specific benefit plan document); and
CMS DME MAC criteria are met (see above link); and
The item is not otherwise excluded from coverage
Coverage Limitations and Exclusions
When more than one piece of DME can meet the member's functional needs, benefits are available only for the item that meets
the minimum specifications for member needs. Examples include but are not limited to:
? Standard power wheelchair vs. custom wheelchair
Standard bed vs semi-electric bed vs. fully electric or flotation system; this limitation is intended to exclude coverage for
deluxe or additional components of a DME item which are not necessary to meet the member's minimal specifications to
treat an injury or sickness.
Repair and Replacement
Servicing and Repairing Medical Equipment
Repair and replacement of Durable Medical Equipment (DME) is covered and medically necessary in certain circumstances.
For medical necessity clinical coverage criteria, refer to North Carolina Medicaid (Division of Health Benefits) Clinical Coverage
Policy for Medical Equipment, 5A-1 Physical Rehabilitation Equipment and Supplies.
Definitions
Behavioral Management Program: Recommended guidelines for behavior management include: direct behavioral
observations, systematic assessment of environmental and within-patient variables associated with aberrant behavior,
Durable Medical Equipment, Orthotics, Medical Supplies, and Repairs/Replacements (for North Carolina Only) Page 3 of 4
UnitedHealthcare Community Plan Coverage Determination Guideline Effective 04/01/2022
Proprietary Information of UnitedHealthcare. Copyright 2022 United HealthCare Services, Inc.


Does Medicare pay for durable equipment?Medicare will typically pay 80% of the Medicare-allowed amount for most covered durable medical equipment. Your doctor needs to prescribe it for you to use in your home. You are responsible for the other 20%, unless you have other coverage such as a Medicare Supplement plan. Your Medicare deductible applies.

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