Durable Medical Equipment (DME)

The DME items for which RMHP requires prior authorization include the list below.  Coverage of DME items is subject to medical necessity review

To obtain authorization, fax the DME Request Form to RMHP 800-262-2567 or 970-255-5681

Durable Medical Equipment Prior Authorization Request Form

Items must be a benefit of your Evidence of Coverage.  You can check benefit coverage by calling a Rocky Mountain Customer Service Representative.  Please have the description of the item available when calling.

You can reach a Customer Service Representative during normal hours, Monday - Friday. Customer Service contact information.

Other items that require preauthorization are listed under Procedures and Drugs.

DME requiring preauthorization:

  • Alternating Pressure Mattresses and Low-Air Loss Mattresses (Pressure Reducing Support Surfaces - Group 2)
  • Automatic External Defibrillation, Garment Type
  • Augmentive Communicator Device / Speech Generating Device
  • Biofeedback therapy
  • BiPAP
  • Blood pressure monitor
  • Bone Growth Stimulators
  • Commode chair with seat lift mechanism
  • Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes
  • Continuous Home Pulse Oximetry
  • Continuous Passive Motion Machine (CPM)
  • Cough Stimulating Device
  • Crutch substitute
  • Custom Fabricated Wheelchair Cushions (E2609 and E2617)
  • Dialysis Equipment, ESRD Supplies, Water Purifier Softener
  • Dynamic splinting devices
  • Enteral Nutrition, ie. Boost, Ensure 
  • Foot pump
  • Functional Electrical Stimulators (FES)
  • Gait trainer
  • Gloves-sterile and non-sterile
  • Hearing aids - CHP+ and Commercial only
  • High Frequency Chest Wall Oscillation Devices and Air-Pulse Generator System/ VEST Airway Clearance System
  • Hospital bed mattresses and overlays (Pressure Reducing Support Surfaces - Group 3)
  • Hospital Beds (semi-electrical and electrical)
  • Incontinence supplies
  • IPPB Machine and humidifier
  • Mechanical Stretching (Dynasplint) and Continuous Passive Motion Devices (E0936-other than knee)
  • Nerve stimulator for the treatment of nausea and vomiting
  • Neuromuscular stimulator
  • Oral appliance for the treatment of sleep apnea
  • Oxygen and oxygen contents
  • Paraffin Bath Unit (Portable)
  • Passenger Vehicle Restraint System
  • Patient Lifts-Hydraulic, multi-positional transfer system, Electrical multi-positional patient support system
  • Pneumatic compressors and appliances
  • Power Mobility Assistive Equipment (Scooter/Power-Operated Vehicle, Power Wheelchair)
  • Power Tilt in Space Wheelchairs and Reclining Wheelchairs
  • Pressure Reducing Support Surfaces - Group 1 (e.g., Overlays, Pads)
  • Prosthetics-upper limb, lower limb, external power, artificial larynx, tracheostomy speaking valve
  • Protime/Coagucheck/INR Monitors
  • Repairs for all equipment and prosthetics
  • Scooters (POV)
  • Shipping/Freight
  • Stroller
  • TENS units and Transcutaneous Electrical Joint Stimulation Device System
  • Traction
  • UVB Light Cabinet for Home Phototherapy
  • Weighted blanket/ Weighted vest
  • Wheelchairs, manual and electrical
  • Wheelchair accessories
  • Wound Vac
Rocky Mountain Health Plans reserves the right to change this list at any time without notice. Rocky Mountain Health Plans does not guarantee that this list is complete or current.