MedicaidCoverageMedium impact
Medical Supplies, Equipment and Appliances Durable Medical Equipment - MEDICAID - SOUTH CAROLINA (Revised)
Humana·SC · Pediatrics, Physical Therapy, Occupational Therapy +2 more·Medicaid
Effective date
Aug 26, 2026
We identified it
Aug 25, 2026
Summary
Humana updated its South Carolina Medicaid DME/MSEA coverage policy effective 08/26/2026, establishing specific medical necessity criteria for durable medical equipment and clarifying coverage determinations for common items like pediatric walkers, hospital beds, and compression therapy devices. The policy explicitly denies coverage for several items (UpSee Mobility Device, Splashy Bath Seat, Safety Sleep Beds, Snoo Smart Sleep Bassinet, and Flexitouch Plus System) due to insufficient clinical evidence. Billing teams must familiarize themselves with these non-covered items and the reinforced criteria requiring provider documentation, medical necessity substantiation, and cost-effectiveness determinations.
Action Required
By 08/26/2026, the billing team must: (1) Update the DME/MSEA approval matrix in the billing system to reflect non-covered items: UpSee Mobility Device (E1399), Splashy Bath Seat (E1399), Safety Sleep Beds including Abrams Safety Sleeper, Courtney Bed, Cubby Plus, Safe Haven, Sleep Safe Bed (E1399), Snoo Smart Sleep Bassinet (E1399), and Flexitouch Plus System (E0659). These items should trigger automatic denial with reference to this policy. (2) Configure prior authorization requirements to mandate provider documentation of medical necessity for all remaining covered DME items, including specific functional limitations justifying the equipment. (3) Educate providers that duplicate equipment (same function for multiple locations like school or work) and non-medically necessary add-ons/upgrades are not covered. (4) Train billing staff on replacement criteria: equipment generally not replaced more frequently than every 5 years unless condition changes or irreparable damage occurs; repairs covered only if warranty expired and repair cost is less than replacement. (5) Update denial reason codes to distinguish between items explicitly listed as not medically necessary versus those requiring prior auth. Failure to implement these changes will result in claim denials and potential member billing issues.