Durable Medical Equipment Guide

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)

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

The following is a list of DME requiring prior authorization including: rental items, purchased items, or items priced under $500.

Adult Undergarments

Ambulatory Aids WSI requires prior authorization for the purchase of one of these DME items. If renting, authorization is only required if the rental timeframe extends beyond 60 days.

• Roller aid & non-motorized scooters
• Walkers
• Wheelchairs & wheelchair accessories 

Catheters If approved for the life of a claim, authorization is not required for each month’s supply.

Continuous Passive Motion Device (CPM) Not covered for shoulder or uncomplicated total knee surgeries

CPAP Unit

Electro Medical Device Submit the prior authorization request in myWSI or complete the Electro Medical Device Request (M5) form and include the prescription or order. Units must be supplied by CPR Medical.

• Combination unit (All-Stim)
• Neuromuscular stimulator
• TENS unit

External Bone Growth Stimulator Submit the prior authorization request in myWSI or complete the Prior Authorization Review Request (UR-C) form.

Eyewear Providers must request any add-ons along with the request for the eyewear.

• Frames
• Lenses/contact lenses
• Anti-reflective coating
• Polarization
• Progressive lenses
• Scratch resistant or tinting coating

Hearing Aids

Home Traction Unit (Cervical or Lumbar) Injured employee must have had recent physical therapy.

Nebulizer If approved for the life of a claim, authorization is not required for each month’s supply.

Orthopedic Footwear Require order from treating provider. Authorization must be approved prior to dispensing. Authorization required for footwear; orthotic shoes; or orthotics (customized or molded)

• Shoes/boots
• Miscellaneous customized shoe additions

Orthopedic Footwear Inserts (customized or molded) Off the shelf inserts fitted to the injured employe’s foot are not considered customized or molded and do not require prior authorization.

Paraffin Bath Unit

Prosthetics

Wound VAC Unit Approval for rental of the unit only.

The following are items WSI will cover if related to the work injury; however, this is not an all-inclusive list. 

• Intermittent compression socks (post-surgical)
• Pneumatic compression devices
• Surgical trays