Durable Medical Equipment and Supplies Clinical Coverage Policy No: 5A - Amended Date: November 1, 2015

Sep 4, 2026

Clinical coverage policy for Durable Medical Equipment and Supplies under North Carolina Medicaid and Health Choice, designated Policy No: 5A and amended November 1, 2015. The policy defines the procedures, products, and services covered, including general and specific coverage criteria for both Medicaid and NCHC, plus additional criteria unique to each program. It also states when items are not covered and outlines eligibility requirements. Coverage rules include prior approval, documentation of medical necessity, and detailed category-specific coverage and limitations.

LanguageEnglish

CategoryForms

FormatPDF

Pages161

Reading Time56 min

AccessFree to download

Table of Contents

Description of the Procedure, Product, or Service

Eligibility Requirements

When the Procedure, Product, or Service Is Covered

When the Procedure, Product, or Service Is Not Covered

Requirements for and Limitations on Coverage

NC Division of Medical Assistance Medicaid and Health Choice Durable Medical Equipment Clinical Coverage Policy No: 5A and Supplies Amended Date: November 1, 2015 Table of Contents 1.0 Description of the Procedure, Product, or Service ........................................................................... 1 1.1 Durable Medical Equipment and Supplies.......................................................................... 1 1.2 Categories of Durable Medical Equipment and Supplies ................................................... 1 2.0 Eligibility Requirements .................................................................................................................. 2 2.1 Provisions............................................................................................................................ 2 2.1.1 General................................................................................................................... 2 2.1.2 Specific .................................................................................................................. 2 2.2 Special Provisions ............................................................................................................... 3 2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a Medicaid Beneficiary under 21 Years of Age ....................................................................... 3 2.2.2 EPSDT does not apply to NCHC beneficiaries .....................................................4 2.2.3 Health Choice Special Provision for a Health Choice Beneficiary age 6 through 18 years of age ....................................................................................................... 4 3.0 When the Procedure, Product, or Service Is Covered......................................................................4 3.1 General Criteria Covered .................................................................................................... 4 3.2 Specific Criteria Covered.................................................................................................... 4 3.2.1 Specific criteria covered by both Medicaid and NCHC ........................................4 3.2.2 Medicaid Additional Criteria Covered................................................................... 5 3.2.3 NCHC Additional Criteria Covered ...................................................................... 5 4.0 When the Procedure, Product, or Service Is Not Covered ............................................................... 5 4.1 General Criteria Not Covered ............................................................................................. 5 4.2 Specific Criteria Not Covered............................................................................................. 5 4.2.1 Specific Criteria Not Covered by both Medicaid and NCHC................................ 5 4.2.2 Medicaid Additional Criteria Not Covered............................................................ 5 4.2.3 NCHC Additional Criteria Not Covered................................................................ 5 5.0 Requirements for and Limitations on Coverage .............................................................................. 6 5.1 Prior Approval .................................................................................................................... 6 5.2 Prior Approval Requirements ............................................................................................. 6 5.2.1 The General ........................................................................................................... 6 5.3 Documenting Medical Necessity ........................................................................................ 6 5.3.1 Hospital Beds, Pediatric Beds and Related Supplies ............................................. 6 5.3.2 Pressure-Reducing Support Surfaces—

FAQs

What does Policy No: 5A cover?

Policy No: 5A covers durable medical equipment and supplies under North Carolina Medicaid and Health Choice, including specific categories of covered items and required clinical criteria.

What are the key eligibility requirements?

Eligibility requirements include general and specific provisions, along with special provisions such as an EPSDT exception for eligible Medicaid beneficiaries under 21 and program-specific exceptions for NCHC.

When is prior approval required and how is medical necessity documented?

Coverage requirements include prior approval and documentation of medical necessity, with detailed documentation guidance for multiple equipment and supply categories.

Sep 4, 2026

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