All PlansCoverageHigh impact
General Medical Necessity Guidance for Durable Medical Equipment, Prosthetic, Orthotics and Supplies (DMEPOS)
Regence BlueShield·Orthopedics, PM&R (Physical Medicine & Rehab), Physical Therapy +2 more·Medical Policy
Effective date
Jan 1, 2026
We identified it
Jun 16, 2026
Summary
New comprehensive medical policy establishes general medical necessity criteria for all durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). The policy requires FDA approval, meeting DME definitions, CMS compliance, and specifies numerous excluded items like safety equipment, convenience items, and recreational devices.
Action Required
By January 1, 2026: Billing team must update DMEPOS claim review processes to verify all four criteria are met: FDA approval, DME definition compliance, medical necessity per CMS guidelines, and least costly appropriate option. Update denial processes for excluded items including safety equipment, convenience items, recreational devices, and home modifications. Train staff on new medical necessity requirements and exclusion categories.