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Coverage criteria policies

DME Benefits Grid

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 not applicable for items listed below


Items listed below generally covered subject to the indications listed below and per your plan documents.

Please see Related Content box to the right for links to MHCP Provider Manual: Equipment and Supplies and MHCP Medical Supply Coverage Guide.

Indications that are covered

See grid below

Indications that are not covered

See grid below

If available, codes are listed for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

DME item




Aids for visually impaired diabetics, such as: syringe magnifier (i.e. Magni-Guide), blood collection dropper (i.e. Smart Dot, Sure Shot), and non-visual insulin measurement device (i.e. Count-A-Dose).



Air compressor




Ambu bag




Anti-nausea wristband

Not covered - over the counter

Anti-nausea wristbands are not covered, as they are a non-prescription item, available for purchase over the counter.



Apnea monitor

Covered - rental

Apnea monitors and memory units are available for rental only. Associated supplies are covered. An apnea monitor kit is covered as a one-time purchase with the initial rental of the monitor.

E0618, E0619

Aqua K pad and pump


Covered if it is a part of a treatment plan, such as for deep vein thrombosis or cellulitis.

E0217, E0249

Bath bench

Not covered - hygienic

Bath benches/chairs, including tub transfer bench, are considered hygienic equipment and not covered.

E0245, E0247, E0248


Covered for limited devices

Replacement batteries are generally covered for the following items:

1. Power wheelchairs and scooters

2. Batteries for member's covered power assist wheels

3. Zinc air battery for use with cochlear implant

Replacement batteries are generally not covered for the following items including, but not limited to:

1. Diabetic Monitors

2. Hearing Aids

3. TENS Units

A4233, A4234, A42.35, A4236, A4601, A4602, A4611, A4638, E1356, E2358, E2359, E2360, E2361, E2362, E2363, E2364, E2365, E2366, E2367, E2371, E2372, E2397, K0601, K0602, K0603, K0604, K0605, K0607, K0733, L7360. L7364, L7367, L8505, L8621, L8622, L8623, L8624, Q0496, Q0503, Q0506, V5266

Bed pan


Coverage is limited to one and the member must be confined to bed.

E0275, E0276

Bedwetting/enuresis alarms


Bedwetting alarms are generally not covered because they are considered a household item or for comfort or convenience, which is excluded in your member contract.

A bedwetting alarm is covered if it is prescribed by a physician prior to the member's possible use of medications for the treatment of enuresis.


Bilirubin lights


Coverage is limited to daily rental only for home phototherapy and associated supplies for hyperbilirubinemia.


Blood glucose test strips and their monitors/meters

Preferred blood glucose test strips and their monitors are covered. Non-preferred blood glucose test strips require prior authorization from pharmacy

The preferred Blood Glucose Testing Product List is available within the Drug Formulary.

There is a quantity limit of 200 blood glucose test strips per month for both preferred and non-preferred products. Larger amounts of test strips can be requested from HealthPartners Pharmacy Services if medically necessary.


Bronchial drainage board


Also referred to as a postural drainage board, bronchial drainage table or tilt table.


Cane or crutches


Cane - The purchase of a standard single point, three prong, or quad cane is covered. Replacement tips are also covered. Upgrade styles are not covered. Canes are limited to one per member

Crutches - The purchase of one pair is covered. Standard, regular, adjustable, wooden or aluminum, forearm, platform, lofstrand, and Canadian varieties are covered. Replacement grips, tips, and underarm pads are also covered.

E0100, E0105, E0110, E0111, E0112, E0113, E0114, E0116, E0117



Not Covered - shower commode, or rolling commode

A Standard, wide or extra wide commode is covered for purchase only when:

• The member is bed or room confined

• The member's bathroom is different level of home from the bedroom

• upon discharge from the hospital or skilled nursing facility immediately post-total hip replacement

The only styles covered are basic backless, standard, or beside. Drop arm commode is covered if medically necessary (i.e. member needs for sliding board transfers).

E0163, E0165, E0168, E0170, E0171

cotton balls, alcohol wipes, rubbing alcohol, and Sharps containers

Not covered


Danny sling


Coverage is limited to one and this item is for purchase only, not rental.

No specific code

Diabetic monitoring equipment and supplies for blood glucose and urine ketones, such as: syringes, lancets, lancet devices, control / calibrating solutions (for checking accuracy of testing equipment & test strips), and urine ketone test strips.



Diabetes infusion pump supplies such as infusion sets, needles, tubing and connector, syringe reservoir, sterile insertion-site dressing (i.e. Tegaderm) and tape needed to secure.



DOSER for inhaled medications


The DOSER™ tracks the use of medication taken from a Metered Dose Inhaler (MDI). With its self-contained microcomputer, the DOSER™ counts and displays the number of inhalations remaining in the inhaler and displays the number of inhalations taken in the current day. The DOSER™ also stores the number of inhalations taken in each of the last 30 days in its memory and alerts the user when the MDI is nearly empty. With its self-contained battery, the DOSER™ lasts a full year.


DME for comfort, convenience or recreation

Not Covered



Covered during rental period of a covered DME item

Electrodes are limited to coverage only during the rental period of an item, such as an apnea monitor, bone stimulator or neuromuscular stimulator (NMS or TENS unit).

A4555, A4556, A4595 K0609, L8680


Not Covered - over the counter

Over the counter enema equipment or bowel management kits are not covered because this is considered custodial care and is excluded in your member contract.

Members in Hospice care may receive coverage per their individual hospice benefits.


Haberman Feeders and nipples


This item is a type of bottle feeder used for infants with cleft lip and or palate.



Not Covered for home use

Covered when used with a tracheostomy, oxygen, CPAP, BIPAP or ventilator

Humidifiers are covered only if needed with a tracheostomy, oxygen, CPAP, BIPAP or ventilator. They are rented for short-term use (3 months or less) and purchased for long term needs.

Replacement supplies are covered.

Cool or heated humidity is covered.

A7046, E0550, E0555, E0560, E0561, E0562,

Insulin pumps




Intermittent positive pressure breathing (IPPB)


IPPB is covered for severe respiratory impairment. It may be rented or purchased depending on the length of need.


Iontophoresis machine

Not covered

Not covered for home use as they are a comfort, convenience or recreational items


IV therapy and pump supplies


Supplies related to intravenous (IV) drug infusion, including IV poles, infusion pumps, and dressing supplies are per the home health services benefit. When IV therapy is discontinued, supplies needed to maintain the central line are covered per your Durable Medical Equipment (DME) benefits. These supplies include syringes, needles, dressings, alcohol and / or betadine wipes, saline or heparin flushes, and tape.

A4213, A4220, A4221, A4222, A4223, A4300, A4301, A4305, A4306, E0776, E0781, E0791, K0105, S1015,

K-Y jelly

Not covered - over the counter

Over the counter items, such as K-Y Jelly is covered only when needed for bowel or bladder program

A9999 or E1399

Medical alert systems

Not covered





Coverage is for the basic, standard unit only. Covered supplies are: t-updrafts with tubing (sometimes referred to as medicine cup), filters, aerosol mask, 3cc, 5cc or 30cc vials of saline. Replacement supplies are covered.

A7003, A7004, A7005, A7006, A7007, A7008, A7017, E0570, E0572, E0574, E0575, E0580, E0585



Needles and syringes are covered for intramuscular (IM) or subcutaneous (Subq) injections at home.

A4206, A4207, A4208, A4209, A4212, A4213, A4215, A4232, A4322, A4657, C1715, C1830, C2618, K0552, S8490

Ostomy supplies


Colostomy / Ileostomy / Nephrostomy / Ureterostomy - Covered supplies include belt, pouch, bags, wafer, face plate, insert, barrier, filter, gasket, plug irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, pouch deodorant, gauze and skin barrier preps.

A4357, A4361, A4362, A4363, A4364, A4366, A4367, A4368, A4369, A4371, A4372, A4373, A4375, A4376, A4377, A4378, A4384, A4385, A4387, A4388, A4389, A4390, A4394, A4395, A4396, A4398, A4399, A4400, A4402, A4404, A4405, A4406, A4407, A4408, A4409, A4410, A4411, A4412, A4413, A4414, A4415, A4416, A4417, A4418, A4419, A4420, A4421, A4422, A4423, A4424, A4425, A4426, A4427, A4435, A4450, A4452, A4455, A4456, A4397, A5051, A5052, A5053, A5054, A5055, A5056, A5057, A5061, A5062, A5063,A5081, A5082, A5083 A5093, A5102, A5120, A5121, A5122, A5126, A5131

Overbed table

Covered when enrolled in hospice





Home oximetry is not considered a valid test for diagnosing obstructive sleep apnea. Please see related content at right for link to Portable/unattended/home sleep tests coverage criteria


Parrafin bath-portable

Covered when ordered by a provider

Must have been tried successfully in physical therapy to qualify for coverage. It is a purchase item only. Replacement paraffin wax is covered.


Patient lifts (Hoyer, etc)

Coverage varies

E0625,E0630, E0637 (hydraulic or mechanical lift )are covered

E0635,E0636, E0639 (electric lift

)are not covered

E0625,E0630, E0637, E0635,E0636, E0639

Peak flow meter


A peak flow meter measures expired (exhaled) air volume over a period of time. It is used at home for persons with chronic lung problems.

A4614, S8096, S8097



Rent for short term use and purchase for long term use.


Pleural effusion drainage systems




Prosthetic and/or stump coverings


A prosthetic cover is the outer covering over the soft, foam part of a prosthetic limb or hand. Types of prosthetic covers include but are not limited to cosmetic hose, prosthetic production glove. Prosthetic stump sleeves are used to hold the prosthesis in place and may last 1-3 months.

2 prosthetic stump shrinkers are covered per year.

6 prosthetic stump socks or sheaths are covered per stump every 6 months.

L5704, L5705, L5706, L5707, L5962, L5964, L5966

Prothrombin time monitors




Puctal plugs


Indications that are covered: Punctal plugs are covered when conservative measures for severe eye dryness have failed.

Plugs are considered inclusive to the procedure.





Respiratory assist device


A member's initial RAD will be rented up to the time the payments have reached the purchase price, at which time the machine becomes owned by the member. Replacement RAD may be purchased outright if all of the following criteria are met: The member's RADs are non-functional due to normal wear & tear; AND

The member's RADs are no longer covered under manufacturer's warranty; AND

The member's RADs have been determined by the DME vendor to require repairs which are not cost effective.

E0470, E0471, E0472

Rope and pulley exercisor


Coverage is limited to one immediately post-surgery for shoulder only.



Not covered

Indications that are not covered: Scales, such as bath scales, baby scales, or any scale that is used to measure weight.

Household equipment which includes scales.

A9999 or E1399

Seating support orthoses


Custom seating support orthosis (SSO) is a purchase item only. SSO are covered to maintain trunk alignment and positioning in a wheelchair or stroller.

They are also called upholstered seating support orthosis (USSO).

A wedge or back cushion when it is part of the SSO is covered.

Not covered: The floor stand or floor mobility base are not covered.


Sitz baths



E0160, E0161, E0162



This is a type of inhaler used to assist with administration of medications. Types of spacers include Aerochamber™, Breathancer™, Inhal-Aid™, Inspirease™, Spinhaler-Turbo™ and OptiChamber®.

A4627, S8100, S8101

Splints - durable (long term)


Rigid or semi-rigid splints are covered if they are durable, reusable, made to withstand prolonged, repeated use. Adjustments/repairs due to growth requirements are covered. Replacements are covered only when growth adjustments can no longer be made or when there is a change in condition which affects the function/fit of the device.

L3100, L4370, L4390, Q4049, S8450, S8451, S8452

Splints - durable (short term)


Splints are considered a supply when applied as part of treatment and meant to be removed in the clinic. They may be applied in the emergency room, urgent care or clinic setting and usually are a one-time application and not reusable.

L3100, L4370, L4390, Q4049, S8450, S8451, S8452

Standing frame/stander


Member contracts generally state all covered DME items should be the acceptable standard model, considering the member's medical condition. Manual or hydraulic standers are covered.

A wedge, when it is part of the standing frame, may be eligible for coverage.

E0637, E0638, E0641, E0642

Suction machine and catheters


Coverage is limited to no more than 3 months stock of catheters. A suction machine is covered for rental if needed short term. It is covered for purchase for long term needs.

A7002, A4605, A4624, A4628, E0600, E2000, K0743

Therapeutic light box; table top or desk top lightboxes


Floor stands, carrying case, and optional desk stands are not covered as they are a comfort, convenience or recreational items


Tracheostomy supplies


Covered items include trach tube, ties (also referred to as twill tape), holders, cannula, tracheostomy care kit, tube brush, pipe cleaners, cotton tip applicators, 4x4 sponge/gauze, saline, sterile water. Thermo Vents™ are disposable items used over the tracheostomy to help create humidity and keep secretions from plugging the trach tube. No more than a 3 month stock is covered at a time. Tracheostomy speaking valve, also called a stint or tracheal esophageal speaking valve, is covered when the member has had a laryngectomy or the larynx is permanently inoperative.

A4481, A4605, A4623, A4624, A4625, A4626, A4629, A7501, A7502, A7503, A7504, A7505, A7506, A7507, A7508, A7509, A7520, A7521, A7522, A7523, A7524, A7525, A7526, A7527, L8501, S8189

Traction equipment

Covered except for spinal unloading devices

Basic standard traction units are covered for cervical and pelvic (low back) traction.

E0830, E0840, E0849

Transfer belt




Transfer board


A basic transfer board is covered


Trapeze bar - over bed



E0910, E0911, E0912

Trend event recorder



C1764, E0616




L8300, L8310, L8320, L8330




E0325, E0326

Urinary supplies



A4321, A4327, A4328, A4331, A4333, A4334, A4351, A4352, A4353, A4356, A4357, A4358, A4360, A5105, A5112

Vaginal cones or dilators



A9999 or E1399

Ventilator and supplies


A ventilator is a rental item only. Supplies (usually purchase only) required to maintain the ventilator are covered.

A4483, A4611, A4612, A4613, E0465, E0466

Vitrectomy table


The face support equipment and necessary chair or table support attachments are covered. Rental only



Not covered

Not covered except for when it is a medically necessary accessory to covered DME

L3340, L3350, L3360, L3370, LL3380, L3390, L3400, L3410, L3420, L3465

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


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.


For in-network benefits to apply, item must be received from a contracted vendor or provider.

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Policy activity

  • 02/22/2017 - Date of origin
  • 10/02/2017 - Effective date
Revision date
  • 12/18/2017

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