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Medical Policies


1.0 Durable Medical Equipment


1.01 Durable Medical Equipment Introduction 

Medically Necessary and Investigational 

For Blue Cross of Idaho`s definition of medically necessary and investigational, please click here. 
1.01.02 Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure 
1.01.05 Ultrasound Accelerated Fracture Healing Device 
1.01.06 Home Apnea Monitoring
1.01.09 Transcutaneous Electrical Nerve Stimulator (TENS)
1.01.10 Continuous Passive Motion (CPM) in the Home Setting
1.01.11 Adjustable Cranial Orthoses for Positional Plagiocephaly and Craniosynostoses
1.01.13 H-wave Electrical Stimulation 
1.01.14 Home Prothrombin Time Monitoring 
1.01.15 Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders 
1.01.16 Negative Pressure Wound Therapy in the Outpatient Setting  
1.01.17 Pelvic Floor Stimulation as a Treatment of Urinary and Fecal Incontinence 
1.01.18 Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
1.01.19 Threshold Electrical Stimulation as a Treatment of Motor Disorders 
1.01.20 Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid 
1.01.22 Skin Contact Monochromatic Infrared Energy as a Technique to Treat Cutaneous Ulcers, Diabetic Neuropathy, and Miscellaneous Musculoskeletal Conditions 
1.01.23 Transtympanic Micropressure Applications as a Treatment of Meniere`s Disease 
1.01.24 Interferential Stimulation for Treatment of Pain
1.01.26 Cooling Devices Used in the Outpatient Setting 
1.01.27 Electrical Stimulation for the Treatment of Arthritis 
1.01.28 Post-Surgical Outpatient Use of Limb Compression Devices for Venous Thromboembolism Prophylaxis
1.01.29 Tumor-Treatment Fields Therapy for Glioblastoma
1.01.98 Breast Pump Rental
1.01.99 Insulin Infusion Pumps for the Treatment of Diabetes Mellitus 
1.01.100 Stretching Devices for the Treatment of Joint Stiffness and Contracture
1.01.101 Continuous Overnight Pulse Oximetry
1.02 Medical Supplies Introduction 
1.02.01 Total Parenteral Nutrition and Enteral Nutrition in the Home 
1.03 Orthotic Devices Introduction 
1.03.01 Orthotics
1.03.02 Knee Braces 
1.03.03  Thoracic-Lumbo-Sacral Orthosis with Pneumatics 
1.04 Prosthetic Appliances Introduction 
1.04.01 Prosthetics
1.04.04 Myoelectric Prosthesis Components for the Upper Limb 
1.04.05  Microprocessor-Controlled Prosthesis for the Lower Limb 



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