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DME Restrictions and Guidelines
PLEASE NOTE: This list is not all-inclusive, as updates
may occur periodically. Refer to the Fee Schedule for
pricing and individual code prior authorization
information.
Restriction
ADHESIVE TAPE LTD TO 240 UNITS PER 30 DAYS BED, HOSPITAL, MANUAL; LTD 1 PER 8 YEARS BEDRAILS, HALF AND FULL; LTD TO 1 PAIR EACH PER 5 YEARS BEDSIDE URINARY DRAINAGE BAGS LTD 12 PER 365 DAYS CATHETER INSERTION TRAYS LTD TO 12 PER 365 DAYS CATHETERS, EXTERNAL; LTD TO 31 PER CALENDAR MONTH CATHETERS, I&O; LTD TO 120 PER CALENDAR MONTH COMPRESSION GARMENTS LIMITED TO 3 PER LEG PER 365 DAYS COMPRESSOR NEBULIZER LTD TO 1 PER 3 YEARS CPAP - CUSHION FOR NASAL MASK INTERFACE LTD TO 2 PER 30 DAYS CPAP - DISPOSABLE FILTER LTD TO 2 PER 30 DAYS CPAP - EXHALATION PORT LTD TO 1 PER 180 DAYS CPAP - FACE MASK INTERFACE LTD TO 1 PER 30 DAYS CPAP - NASAL INTERFACE LTD TO 1 PER 90 DAYS CPAP - NON-DISPOSABLE FILTER LTS TO 1 PER 180 DAYS CPAP - ORAL CUSHION FOR MASK LTD. 2 PER 30 DAYS CPAP - ORAL INTERFACE LTD TO 1 PER 180 DAYS CPAP - PILLOW FOR MASK/NASAL CANULA INTERFACE LTD. TO 1 PAIR PER 30 DAYS CPAP - WATER CHAMBER FOR HUMIDIFIER LTD TO 1 PER 180 DAYS DIABETIC BLOOD GLUCOSE TESTSTRIPS LTD 36 PER 6 MONTHS DIABETIC LANCET LTD 18 UNITS PER 6 MONTHS DIABETIC SYRINGES LTD TO 100 PER 30 DAYS DISPOSABLE INCONT PRODUCTS LIMIT 300 PER CALENDAR MONTH DRESSING, DIABETIC TRANSPARENT; LTD.TO 50 DRESSINGS PER CALENDAR DRESSING, SPEC ABSORPTIVE; LIMITED TO 30 PER CALENDAR MONTH DRESSINGS, GAUZE; LIMITED TO 400 PER CALENDAR MONTH ENTERAL AND PARENTERAL SUPPLIES LTD TO ONE TYPE PER DAY ENTERAL SUPPLIES LTD TO $200.00 PER CALENDAR MONTH GLOVES, NON-STERILE; LIMITED TO 1200 PER 365 DAYS GLOVES, STERILE; LIMITED TO 50 PAIR PER MONTH GLUCOMETERS LIMITED TO ONE PER FIVE YEARS. GRADIENT PRESSURE AIDES LIMITED TO 3 PER ARM PER 365 DAYS (Includes BREAST PROSTHESES; MASTECTOMY SLEEVE) GRADIENT STOCKING GARTER BELT LIMITED TO 2 PER 365 DAYS HEEL PAD WITH SPUR DEPRESSION LTD TO 2 PER FOOT PER 365 DAYS INFUSION SET FOR EXT INSULIN PUMP LTD 190 PER 365 DAYS KLING TYPE BANDAGES LTD TO 240 YARDS PER 30 DAYS LIMIT REPLACEMENT SLING TO ONE PER 365 DAYS MASTECTOMY BRAS LIMITED TO 2 PER CALENDAR YEAR MASTECTOMY FORMS LTD TO 1 PER SIDE PER YEAR OCULAR PROSTHESIS POLISHING AND CLEANING LTD TO ONCE PER 365 DAYS cleaning ORTHOTIC INSERTS LTD.TO PER FOOT Per 180 days OSTOMY BARRIERS LTD TO 15 PER CALENDAR MONTH OSTOMY BELTS ADJUSTABLE; LTD TO 3 PER 365 DAYS OSTOMY POUCHES, CLOSED; LTD TO 45 PER 30 DAYS OSTOMY POUCHES, DRAINABLE; LTD TO 15 PER 30 DAYS PRESSURE-DISPLCNG ANKLE/FOOT ORTHTC LTD 1 PER FOOT PER 2 YEARS PROSTHETIC HAND REPLCEMENTS LTD 1 PER HAND PER 5 YEARS REUSABLE INCONTINENCE PRODCUTS LTD 36 PER 365 DAYS SHOE MODIFICATIONS LTD TO 1 FOOT PER PER 180 DAYS ORTHOTIC FOOTWEAR LTD 1 PER FOOT PER 180 DAYS SYRING W NEEDLE FOR EXT INFUSION PUMP 15 PER 30 DAYS URINE TEST LABS/STRIPS LTD TO 100 PER 90 DAYS OSTOMY RING LIMITED TO 30 PER 2 MONTH PERIOD TEST MATERIAL FOR INR MONITORING LTD 1 PER 30 DAYS HEARING AID REPAIRS LTD TO 1 RT PER 365 DAYS PERCUSSOR LTD 1MONTH RENTAL & 1 PURCHASE/5 YEARS FEEDER BOTTLES LIMITED TO 10 IN 180 DAYS L8501, SPEAK VALVE, LIMITED TO 2 PER 6 MONTHS RENTAL OF E2402 IS LIMITED TO 1 PER MONTH 1 unit = 1 pump month1 unit = 1 wound care INSULIN INFUSION PUMP LTD TO 1 IN 4 YEARS EXTERNAL TRANSMITTER A9277 LIMITED TO 1 IN 365 DAY DIABETIC CALIBRATION SOLUTION LTD.TO ONCE PER MON.

Source: http://www.vtmedicaid.com/downloads/manuals/DME%20restrictions%20&%20guidelines%205-31-13.pdf