Prior authorization and rental changes for Medicare Advantage and D-SNP durable medical equipment, orthotics, and related supplies

Blue Cross and Blue Shield of North Carolina (Blue Cross NC) is implementing the following changes for Medicare Advantage and Dual Eligible Special Needs Plan (D-SNP) Durable Medical Equipment (DME), orthotics, and related supplies reimbursement to more closely align with Centers for Medicare & Medicaid Services (CMS) requirements:

• Effective October 1, 2026, Blue Cross NC will align with CMS rental requirements and will no longer allow early purchase of DME, orthotics, and related supplies when the item is classified as rental under the CMS Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Fee Schedule. Complex rehabilitative power-driven wheelchairs may be authorized as rental or purchase, per CMS guidelines. Covered equipment must be billed in accordance with applicable billing guidelines.

  • Exception: External ambulatory insulin infusion pumps (HCPCS E0784) are excluded from this change. Purchases of E0784 will continue to be allowed when medical necessity criteria are met.

• Effective January 1, 2027, the following prior authorization changes will apply to purchased Durable Medical Equipment (DME), orthotics, and related supplies:

  • Prior authorization is required for DME, orthotics, and related supplies with a CMS-allowed amount greater than $1,000.
  • Certain DME, orthotics, and related supplies with a CMS-allowed amount of $1,000 or less may also require prior authorization.
  • The CMS-allowed amount, rather than the provider's billed or charged amount, will be used to determine whether an item meets the prior authorization threshold.

Blue Cross NC encourages providers to review internal billing and prior authorization workflows and educate staff about each change before its applicable effective date.

Providers may contact their contract representative with any questions.