17.3.21 Noncovered Rehabilitative and Therapeutic DME

Noncovered rehabilitative and therapeutic DME includes, but is not limited to:

•	Adaptive furniture, bolsters, and wedges.

•	Corner chairs and floor sitters.

•

Creepers.

•	Home modifications, including ramps (except portable ramps for wheelchairs).

•	Hydrocollators.

•	Parallel bars.

•	Powered equipment, including ceiling or track lifts (except powered wheelchairs and electric beds).

•	Pressure relief beds.

•	Vehicle modifications.

•	Vocational, educational, and recreational equipment, even when adapted.

Other miscellaneous DME may be authorized based on review of documentation of medical necessity. This documentation must be submitted with the authorization request form.

Refer to:

“CSHCN Services Program Prior Authorization and Authorization Request for Durable Medical Equipment (DME),” on page B-28.