Durable medical equipment (DME) including supplies, equipment, prosthetics, orthotics, and braces may be reimbursable if related to the work injury. Workforce Safety & Insurance (WSI) requires a prescription or an order for DME by the treating provider.
Reimbursement is per the WSI Fee Schedule, and WSI does not directly pay the injured employee.
Final liability and payment decisions are the responsibility of the WSI Claims Adjustor managing the claim.
When submitting a bill for DME a provider should:
- Bill with the appropriate HCPC code
- Bill each charge separately and not bundle the charges
- Submit a description for a miscellaneous DME code
Use of a miscellaneous code is appropriate as indicated below:
- If no specific listed code is available for equipment that is new or unique
- If equipment is customized or substantially modified to meet the specific needs of the injured employee
- For labor charges related to the service(s)
All DME over $500 requires prior authorization. DME listed below are additional DME items requiring prior authorization even though they may be under the $500 threshold.
To submit a prior authorization review request
- Access the Lookup Claim application to obtain the claim status. WSI will only review a request for DME on an accepted claim.
- Review this guide to determine if prior authorization is required.
- Call the WSI claims adjuster at 701-328-3800 or 800-777-5033
All DME rental items extending beyond 60 days require prior authorization. Total rental payments for DME covered by WSI may not exceed the purchase price.
Submit the prior authorization request in myWSI or complete the Electro Medical Device Request (M5) form and include the prescription or order.
DME Requiring Prior Authorization
The following is a list of DME requiring prior authorization including: rental items, purchased items, or items priced under $500.
Includes
- Roller aids and non-motorized scooters
- Walkers
- Wheelchairs and wheelchair accessories
- Continuous Passive Motion (CPM) device
- Orthopedic footwear
- Shoes or boots
- Customized shoe additions
- Orthotics
- Inserts (customized or molded)
Not covered
CPM devices are not covered for shoulder or uncomplicated total knee surgeries.
Prior authorization required
Ambulatory equipment requires prior authorization for the purchase of these items. If renting, authorization is only required when the rental timeframe extends beyond 60 days.
Orthopedic footwear and orthotics require an order from the treating provider and must be approved prior to dispensing.
Additional information
Off-the-shelf inserts fitted to the injured employee’s foot are not considered customized or molded and do not require prior authorization.
Includes
- Continuous Passive Motion (CPM) device
- Orthopedic footwear
- Shoes or boots
- Customized shoe additions
- Orthotics
- Inserts (customized or molded)
Not covered
CPM devices are not covered for shoulder or uncomplicated total knee surgeries.
Prior authorization required
Orthopedic footwear and orthotics require an order from the treating provider and must be approved prior to dispensing.
Additional information
Off-the-shelf inserts fitted to the injured employee’s foot are not considered customized or molded and do not require prior authorization.
Includes
- Combination unit (All-Stim)
- Neuromuscular stimulator
- TENS unit
- Neurotech Kneehab unit
- External bone growth stimulator
Prior authorization required
Electro medical device and Neurotech Kneehab submit the prior authorization request in myWSI or complete the Electro Medical Device Request form and include the prescription or provider order.
External bone growth stimulator submit the prior authorization request in myWSI or complete the Prior Authorization Review Request form.
Additional information
Units must be supplied by CPR Medical when applicable.
Includes
- CPAP unit
- Nebulizer
- Home traction unit (cervical or lumbar)
- Paraffin bath unit
Prior authorization required
Authorization is required for these items.
Additional requirements
Home traction units require the injured employee to have completed recent physical therapy.
Ongoing supplies
If approved for the life of a claim, authorization is not required for each month’s supply (nebulizer).
Includes
- Catheters
- Adult undergarments
Prior authorization required
Authorization is required unless otherwise approved for the life of the claim.
Ongoing supplies
If approved for the life of a claim, authorization is not required for each month’s supply.
Includes
- Eyewear
- Frames
- Lenses or contact lenses
- Anti-reflective coating
- Polarization
- Progressive lenses
- Scratch-resistant or tinting coatings
- Hearing aids
Prior authorization required
Authorization is required for these items.
Additional requirements
Providers must request any add-ons at the time of the initial authorization request.
Includes
- Prosthetics
- Wound VAC unit
Prior authorization required
Authorization is required for these items unless otherwise noted.
Additional information
Wound VAC units are approved for rental only.
Prior Authorization Not Required - Unless over $500
The following are items WSI will cover if related to the work injury; however, this is not an all-inclusive list.
- Cam Boot
- Cane/crutches
- Cervical collar
- Cervical pillow
- Compression garments/TED hose
- Darco Shoe
- Hand gripper
- Knee sleeves
- Lumbar/SI belt
- Miracle Ball
- Occipivot
- Off-the-shelf shoe inserts/wedges
- Over-the-door pulley system (post-shoulder surgery)
- Physioball
- Postural restoration 4-6in ball (PRI ball)
- Prosthetic sleeves
- Rib belt
- Shower bench/Chair
- Splint/brace
- Toilet riser/Commode
- Taping supplies
- Theraband
- Theracane
- Theraputty
- Yoga Blocks
Packaged Services – Not separately reimbursed
- Intermittent compression socks (post-surgical)
- Pneumatic compression devices
- Surgical trays
Not Covered Durable Medical Equipment
- Compression devices for intermittent compression with various wraps for arms or legs, e.g., VascuTherm or any hot or cold compression device (purchase or rental)
- Continuous-flow cryotherapy unit, e.g., Game-ready unit or any water/ice circulation unit
- Electric heating pad
- Home gym exercise equipment, e.g., weights, weight machine, exercise ball
- Hot or cold packs
- H-Wave electrical stimulation units
- Instrument Assisted Soft Tissue Mobilization Tools
- Wave Accelerated Recovery Performance (ARP) e.g. patented Bio-Electric Waveform Therapy
- Yoga Mata