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Good Afternoon
4:32:03 PM CDT
Thursday, April 24, 2014

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Utilization Review

Topics Forms & Publications Electro Medical Device Certification Request (M5)
General Information Utilization Review Guide Provider Request for Adjustment (M6)
Authorization Process Utilization Review Request (UR-C) Independent Exercise or Work Hardening/Conditioning Program Requests (C59a)
Physical and Occupational Therapy Treatment Window Utilization Review Request (UR-C) Guidelines Quick Tips for Physical & Occupational Therapists
Durable Medical Equipment (DME) Post Injection Pain Response Note  
Treatment Guidelines    

Durable Medical Equipment (DME)

Durable medical equipment costing $500 or more requires prior authorization from the 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, complete the Electro Medical Device Certification Request (M5) form along with the prescription from the physician 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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