Utilization Review
Any durable medical equipment exceeding $500 requires prior authorization from the WSI claims adjuster.
Reimbursement to the medical provider may be denied if prior authorization is not requested.
EXCEPTION: Electro medical devices such as TENS units, combination units, or muscle
stimulators require prior authorization from the WSI claims adjuster. To request approval for
these units the Electro Medical Device Certification Request (M5) form should be completed.
This form, along with the prescription from the physician, must to be submitted to WSI. The
unit will be mailed directly to the provider requesting the device within 24 hours of the DME
Company verifying the correct mailing address.
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