Equipment and Supplies

PrimeWest Health covers medical equipment and supplies, subject to limitations, authorization, and other requirements. Additional restrictions apply to medical equipment and supply coverage for members residing in long-term care facilities (LTCFs).

1. When the medical equipment or supply is purchased for a member, the item is the member’s property.
2. Depending on the member’s coverage (Medicare or Medicaid primary), rent for most Durable Medical Equipment (DME) is covered (if medical necessity criteria are met) for the applicable Medicare or Medicaid coverage period based on InterQual® criteria, or to the purchase price of the equipment. After 13 months of rental, or when the purchase price is reached, the item is the member’s property.
3. DME determined by Medicare to require frequent and substantial servicing is not subject to the 13-month rental limit.
4. PrimeWest Health assumes a reasonable useful lifetime of five years for all DME.
5. PrimeWest Health will not cover equipment that serves the same purpose as usable equipment previously purchased for the member.
6. PrimeWest Health covers repairs to medically necessary member-owned equipment and maintenance on equipment that requires frequent cleaning and/or routine calibration to ensure proper working order.
7. All purchased equipment must be new upon delivery to the member. Equipment that is intended to be rented until converted to purchase must be new equipment. Used equipment may be used for short-term rental, but if eventually converted to purchase, it must be replaced with new equipment.

To determine the appropriate Healthcare Common Procedure Coding System (HCPCS) code to use with a covered service, access the Medicare Pricing, Data Analysis, and Coding (PDAC) Product Classification List.

Living Arrangement Codes

41: NFI (Nursing Facility I) Medicare Cert
42: NFII (Nursing Facility II) Non-Medicare Cert
43: Intermediate Care Facility for the Developmentally Disabled (ICF/DD) – Public/Private
44: Short-Term Stay NFI
45: Short-Term Stay NFII
46: Short-Term Stay ICF-DD
48: Medical Hospital
55: Rule 203 – Adult Foster Home
80: Community

Coverage Criteria

PrimeWest Health uses nationally accepted criteria such as InterQual^®, clinical practice guidelines, State of Minnesota coverage policies, Minnesota Department of Human Services (DHS) and/or Centers for Medicare & Medicaid Services (CMS) guidelines, etc. Upon request from a provider, member, regulator, or commissioner of commerce, PrimeWest Health will provide the criteria used to determine medical necessity, appropriateness, or efficacy of a service.

All services provided by out-of-network or non-contracted providers, including medical suppliers or DME providers, require a Service Authorization prior to the sale or rental of any Durable Medical Equipment, prosthetics, orthotics, or supplies (DMEPOS). Skilled Nursing Facilities (SNFs) that are contracted with PrimeWest Health who usually do business with DME providers or suppliers are encouraged to use in-network providers whenever possible for these items/supplies. However, if a provider is used that is not contracted with PrimeWest Health, the SNF can continue utilizing those suppliers without a separate out-of-network authorization from PrimeWest Health. Service Authorization is still required for the specific DMEPOS if it is part of the Service Authorization list indicated below.

Contracted providers or in-network providers require a Service Authorization for the following DMEPOS. Also see Service Authorizations for more specific information regarding Service Authorizations.

Face-to-Face Rule for Durable Medical Equipment, Appliances, and Supplies

Effective January 1, 2018, PrimeWest Health members are required to have a face-to-face encounter with a physician and certain authorized non-physician practitioners before ordering certain medical equipment, appliances, and supplies within six months before the start of service (initial dispensing date).

Non-physician practitioners including a nurse practitioner, clinical nurse specialist, or physician assistant are authorized to conduct face-to-face encounters.

Physician assistants are required to work under the supervision of the physician.

Only DME items subject to the face-to-face rule by Medicare are subject to the rule by MHCP. A list of items subject to the face-to-face rule may be found in Chapter 3 of the DME MAC Jurisdiction B Supplier Manual. Refer to the Medicare contractor supplier documentation, ACA 6407 Specified Items, pages 11 – 17.

Face-to-face encounters may occur through telehealth. 

Exclusions: nurse midwives, audiologists, and podiatrists

Face-to-Face Documentation

Providers must maintain written or electronic documentation of face-to face encounters on file and available to DHS upon request. Documentation must include the following:

1. The identity of the physician or non-physician practitioner who conducted the face-to-face encounter. Non-physician practitioners are authorized to complete the documentation requirements.
2. The date of the face-to-face encounter.
3. The specific diagnosis or medical condition that was the reason for the face-to-face encounter and ordered service.

Documentation of face-to-face encounters by the physician or non-physician practitioner may be included in clinical and progress notes and discharge summaries.

Documentation for the medical supplier’s records may be copies of physician or non-physician practitioner notes, documentation of a phone call with the physician or non-physician practitioner to confirm the face-to-face, or a written summary from the physician or non-physician practitioner. All forms of documentation must include the identity of the physician or non-physician practitioner who completed the face-to-face encounter, the date of the face-to-face encounter, and the specific diagnosis or medical condition that was the reason for the face-to-face encounter and ordered service.

Ongoing Services

Ongoing services are not subject to the face-to-face rule. A face-to-face encounter is only required for new medical equipment, supplies, or appliances.

Financial Implications

PrimeWest Health will assume providers are in compliance with the face-to-face rule (42 CFR Part 440) for claims submitted on or after January 1, 2018. Payment for services can be subject to payment recovery for which a timely face-to-face encounter was not documented.

The following codes require a face-to-face encounter visit as defined above.

For contracted providers, PrimeWest Health will allow the 3-month rental without an authorization and face-to-face encounter documentation for the following codes:

1. Geri Chair: E1031
2. Transport Chair: E1037, E1038, E1039
3. Manual Wheelchairs: K0001, K0002, K0003, K0004

At the end of the 3-month rental, if the DME is still medically necessary, the face-to-face encounter guidelines fall into place.

All claims for DME and/or supplies for $1,500 or more require Service Authorization before being submitted for payment. This is for contracted medical suppliers only. Non-contracted or out-of-network suppliers require Service Authorization regardless of amount billed.

Reclassification of Certain Durable Medical Equipment (DME) to the Capped Rental Payment Category

Effective April 1, 2014, certain DME HCPCS codes from the Inexpensive and Routinely Purchased DME payment category were reclassified to the Capped Rental DME payment category.

As shown in Attachment A of Medicare Learning Network (MLN) Matters # 8566, the effective date is April 1, 2014 for HCPCS codes not included in a Competitive Bidding Program (CBP). A forthcoming change request will address the codes that will be reclassified to the Capped Rental DME payment category effective July 1, 2016 and January 1, 2017.

Authorization Requirements

The provider must obtain authorization when required. See the Medical Supply Coverage Guide for more information about when authorization is required.

1. The provider may not request or accept payment from the member for any service for which the required authorization was not obtained.
2. List all add-on items on separate lines on the authorization request, even if the individual item does not require authorization. List each item by HCPCS code, appropriate modifier, quantity and charge.
3. Authorization is required for all supply requests over the allotted units allowed.
4. PrimeWest Health will not authorize more units per line than are allowed by Medicare’s Medically Unlikely Edits (MUEs). When requesting authorization for bilateral prosthetics or orthotics where more units are required than are allowed by the MUEs, the units must be requested on different lines, with modifiers NU RT and NU LT or other approved modifiers as appropriate.
5. When requesting multiple items that are different but require the same miscellaneous code, list each item on a separate line of the authorization request. A unique description of each item must be entered into the model number field for each line. The unique description may be a model number or narrative description up to 20 characters.
6. Documentation must address the member’s medical need. For prosthetics, orthotics, mobility devices, and similar items that include multiple components with distinct HCPCS codes, list the HCPCS for each accessory on its own line.
7. When authorization is required, list all requested parts or accessories on the authorization request. If approved, the approved rate will include all requested and approved parts or accessories.
8. Attach the manufacturer’s pricing. PrimeWest Health will accept a price list or a quote from the manufacturer dated within three months of the authorization request. If manufacturer pricing is not available, PrimeWest Health will accept an invoice. Clearly indicate each item being requested. Do not modify, alter, or change the pricing documentation (highlighting, starring, or circling is allowed).
9. Prior authorization is required for all repairs when parts and labor total over $1,000 for DME.
10. Modifiers KH, KI, and KJ apply to any authorization request for a capped rental item. Each K modifier must be on a separate line on the authorization request.
11. Authorization is required for all DME purchases and rentals when the same HCPCS code has been provided to the member in the past 16 months.
12. Authorization is required for new equipment that is provided due to the same equipment not lasting the reasonable five-year lifetime.
13. Authorization is required for all supply requests over the allotted units allowed.

Authorization Requests for Typically Noncovered Items

Authorization can be requested for any piece of medical equipment, supply, prosthetic, or orthotic that is typically considered a non-covered item. The item must be medically necessary. Enter this request under the HCPC code specified for the item and submit documentation that demonstrates the item meets all the following criteria:

1. Medically necessary, as determined by prevailing medical community standards or customary practice and usage
2. Appropriate and effective for the member’s medical needs
3. Timely, considering the nature and present medical condition of the member
4. Provided by a provider with appropriate credential
5. The least expensive, appropriate alternative available
6. An effective and appropriate use of PrimeWest Health funds
7. Not investigative or investigative, but should be approved for compassionate use
8. Suitable for use in the member’s home or any non-institutional setting in which normal life activities take place
9. Is generally not useful in the absence of an illness, injury, or disability
10. Is provided to correct or accommodate a physiological disorder of physical condition or is generally used primarily for a medical purpose.

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Updated_08/08/2025