CommercialCoverageHigh impact
Durable Medical Equipment (DME) and Devices, Standard and Non-Standard 1.01.00
Excellus BlueCross BlueShield·Physical Therapy, Occupational Therapy, Orthopedics +3 more·Durable Medical Equipment & Supplies
Effective date
Aug 21, 2025
We identified it
Jul 28, 2026
Summary
Excellus BlueCross BlueShield has updated its DME and medical device coverage policy effective August 21, 2025. The policy establishes unified medical necessity criteria for standard DME and devices, clarifies repair and replacement eligibility requirements, and reinforces that duplicate equipment, cosmetic upgrades, and equipment damaged through neglect are not covered. Billing teams must ensure all DME and device claims meet specific criteria including physician documentation of compliance, warranty status, and functional impairment impact on activities of daily living.
Action Required
By August 21, 2025: Billing and clinical teams must implement the following: (1) Update claim submission workflows to enforce ALL seven DME medical necessity criteria (medically useful, not useful without illness/injury, physician-ordered, home use, durable, reusable, therapeutic benefit) before processing claims; (2) Require providers to document in all DME repair/replacement requests: date of equipment initiation, manufacturer warranty status, and attestation of patient compliance and continued benefit; (3) Implement system edits to deny claims for duplicate DME items serving the same function, positioning them as member convenience; (4) Stop covering equipment repairs/replacements for damage due to neglect, theft, abuse, or when other insurance (homeowners, auto, liability) is available—obtain insurance information during precertification; (5) For replacements, require documentation that equipment is non-repairable or repair exceeds replacement cost, OR that clinical condition change necessitates replacement; (6) Deny all requests for replacement of properly functioning equipment citing advanced technology or aesthetics; (7) Update prior authorization templates and denial letters to reference specific unmet criteria from this policy. Failure to implement these controls will result in claim denials and potential compliance issues. Route all related policy questions to Compliance and ensure provider communication regarding documentation requirements before the effective date.