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Durable Medical Equipment, Prosthetic and Orthotic Replacements, Duplicates, Repairs, and Upgrades to Existing Equipment
Regence BlueShield·Orthopedics, PM&R (Physical Medicine & Rehab), Physical Therapy +3 more·Medical Policy
Effective date
Jan 1, 2026
We identified it
Jun 16, 2026
Summary
New policy effective January 1, 2026 establishes specific criteria for billing DME, prosthetic, and orthotic replacements, repairs, and upgrades. Key requirements include 5-year minimum lifetime for replacements, restrictions on backup equipment to life-threatening situations only, and specific repair coverage criteria for member-owned equipment.
Action Required
By January 1, 2026: Billing team must update DME billing protocols to require 5-year minimum useful lifetime documentation before processing replacement requests. Update system to flag backup equipment requests as non-covered unless life-threatening. Add medical necessity documentation requirements for all DME repairs on member-owned equipment. Train staff on new prosthetic replacement criteria (60% repair cost threshold). Claims not meeting these criteria will be denied.