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Coverage criteria policies

Durable medical equipment and supplies – Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for some durable medical equipment (DME) items. Please refer to the specific policy for coverage criteria for the requested item.

Prior authorization is not required for DME and supplies that are included in a skilled nursing home’s per diem. Please refer to MN department of Human Services medical supply guide to view items that are included in a nursing home’s per diem.

Covered services that require prior authorization:

Please refer to to view items that require prior authorization.

Covered services that do not require prior authorization

  • Repairs of medical equipment
  • Shoes, when part of a leg brace or when custom molded
  • Batteries for medical equipment
  • Oxygen and oxygen equipment
  • Diabetic equipment and supplies
  • Walkers, crutches, orthotics


Durable Medical Equipment and Supplies are generally covered subject to the indications listed below and the following limits from your member contract:

HealthPartners covers medical supplies and equipment, subject to limitations, authorization, and other requirements. Additional restrictions apply to supply and equipment coverage for members residing in long term care (LTC) facilities. (Please see related content at right for link to coverage policy.)

  1. When the medical equipment or supply is purchased for a member, the item is the member’s property
  2. A reasonable useful lifetime of five years for all durable medical equipment is assumed.
  3. HealthPartners will not cover equipment that serves the same purpose as usable equipment previously purchased for the member.
  4. HealthPartners covers repairs to medically necessary member-owned equipment and maintenance on equipment that requires frequent cleaning or routine calibration to ensure proper working order.

Indications that are covered

Miscellaneous Products

Sharps Disposal Containers

Members who self-administer medications using syringes may receive sharps disposal containers.

QR Powder, Nosebleed QR and WoundSeal Code: A4649 NU

WoundSeal Powder, QR Powder for Lacerations, QR Powder for Kid’s Cuts and Scrapes, QR Powder for Nosebleeds, and Gentle Formulation QR Powder for Nosebleeds are covered when prescribed by a physician for recipients with bleeding disorders, including bleeding disorders caused by use of anticoagulants. The claim must include a diagnosis code specific to the bleeding disorder. Up to four units may be dispensed in anticipation of future need. It is not necessary to open packaging; providers may dispense a box of two or four applications. One unit equals one application.

EarPopper Code: E1399 NU

EarPopper Home Version is covered when prescribed by a physician for recipients over three years old with otitis media with effusion or eustachian tube dysfunction who are unable to independently perform the Politzer maneuver.

Weighted Blankets or Vests Code: E1399 NU

Weighted blankets or vests are covered for recipients who have developmental disabilities, including autism spectrum disorders. The function of the weighted blankets is to provide proprioception (deep pressure), which has a calming effect that allows people with developmental disabilities to interact with their environment. Documentation needs to include relevant diagnoses of the recipient and evaluation performed by an occupational therapist that justifies medical necessity.

See Individual Minnesota Health Care Programs policies for items not on this list.

Indications that are not covered

The following list of noncovered services is not all-inclusive:

  1. Air conditioners
  2. Bathroom scales
  3. Bathtub wall rails
  4. Beds - oscillating and lounge beds, bed baths and lifters, bedboards, tables, and other bed accessories
  5. Blood glucose analyzer - reflectance colorimeter
  6. Car seats, standard use
  7. Cervical roll or pillow
  8. Clothing
  9. Control units and battery device adapters
  10. Dehumidifiers - room or central
  11. Diathermy machines
  12. Disposable wipes - including Attends wash cloths
  13. Disposable ice packs and disposable heat wraps
  14. Elevators and stair lifts that are affixed to the home
  15. Enuresis or bed-wetting alarms
  16. Environmental products (e.g., air filters, purifiers, conditioners, hypoallergenic bedding and linens)
  17. Exercise equipment
  18. Food blenders
  19. Grab bars that are affixed to the home
  20. Heat and massage foam cushion pads
  21. Home security systems
  22. Household equipment and supplies such as ramps, switches, tableware, and feeding instruments
  23. Humidifiers - room type or central
  24. Hygiene supplies and equipment, including hand-held shower units and shower trays, and dental care supplies and equipment.
  25. Instructional materials (e.g., pamphlets and books)
  26. Isolation gowns, surgical gowns and masks
  27. Magnifying glasses
  28. Massage devices
  29. Medical alert bracelets and response systems
  30. Medical supplies defined as drugs
  31. Medication boxes or medication dispensing equipment
  32. Menses products (e.g., sanitary pads)
  33. Modifications to bathrooms
  34. Motorized lifts for a vehicle
  35. Orthopedic mattresses
  36. Personal computers and printers, tape recorders, or video recorders
  37. “Potty” chairs/seats for toilet training children
  38. Pulse tachometers
  39. Ramps that are affixed to the home
  40. Reachers
  41. Reading glasses
  42. Saline or other solutions for the care of contact lenses
  43. Table foods
  44. Telephones, telephone alert systems, telephone arms or answering machines
  45. Tennis or gym shoes
  46. Thermometer covers
  47. Toothbrushes and toothettes
  48. Toys
  49. Washable or reusable incontinence undergarments
  50. Waterbeds
  51. White canes for the blind
  52. Durable medical equipment (DME) and supplies covered under a facility’s per diem are not eligible for separate reimbursement.


This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.


  1. Minnesota Health Care Programs (MHCP) Provider Manual: Equipment and Supplies. Revised 05-23-2017.
  2. Minnesota Health Care Programs (MHCP) Provider Manual: Equipment and Supplies: Bath and Toilet Equipment. Revised 07-28-2011.
  3. Minnesota Health Care Programs (MHCP) Provider Manual: Nursing Facilities, Revised: 04-18-2018

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Policy activity

  • 08/04/2010 - Date of origin
  • 07/01/2017 - Effective date
Review date
  • 06/2017
Revision date
  • 06/25/2018

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