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Page 1: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,
Page 2: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,
Page 3: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,
Page 4: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,
http://www.vtmedicaid.com/#/
http://www.vtmedicaid.com/#/resources
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://humanservices.vermont.gov/rules-policies/health-care-rules/health-care-administrative-rules-hcar/adopted-rules
https://humanservices.vermont.gov/rules-policies/health-care-rules/health-care-administrative-rules-hcar/adopted-rules
Page 5: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,

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http://www.vtmedicaid.com/#/resources
Page 6: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,

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http://www.vtmedicaid.com/#/resources
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
Page 7: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,

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https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/DME_List_of_Specified_Covered_Items_updated_March_26_2015.pdf
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/DME_List_of_Specified_Covered_Items_updated_March_26_2015.pdf
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/DME_List_of_Specified_Covered_Items_updated_March_26_2015.pdf
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/DME_List_of_Specified_Covered_Items_updated_March_26_2015.pdf
https://humanservices.vermont.gov/rules-policies/health-care-rules/health-care-administrative-rules-hcar/adopted-rules
https://humanservices.vermont.gov/rules-policies/health-care-rules/health-care-administrative-rules-hcar/adopted-rules
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://humanservices.vermont.gov/rules-policies/health-care-rules/health-care-administrative-rules-hcar/adopted-rules
https://humanservices.vermont.gov/rules-policies/health-care-rules/health-care-administrative-rules-hcar/adopted-rules
Page 8: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,

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http://www.vtmedicaid.com/#/forms
Page 9: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,

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http://www.vtmedicaid.com/#/manuals
Page 10: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,

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https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://med.noridianmedicare.com/web/jddme/topics/documentation/standard-written-order
Page 11: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,

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https://dvha.vermont.gov/providers/codesfee-schedules
http://www.vtmedicaid.com/#/resources
Page 12: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,

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Page 13: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,

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https://dvha.vermont.gov/forms-manuals/forms
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html
Page 14: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
Page 15: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
http://www.vtmedicaid.com/#/home
Page 16: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,

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https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
Page 17: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,

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http://www.vtmedicaid.com/#/manuals
https://med.noridianmedicare.com/documents/2230703/7218263/Oxygen+and+Oxygen+Equipment+LCD+and+PA
https://med.noridianmedicare.com/documents/2230703/7218263/Oxygen+and+Oxygen+Equipment+LCD+and+PA
Page 18: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
Page 19: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://dvha.vermont.gov/providers/codesfee-schedules
http://www.vtmedicaid.com/#/manuals
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
https://dvha.vermont.gov/forms-manuals/forms/prior-authorizations-tools-and-criteria/durable-medical-equipment
Page 20: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,

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https://humanservices.vermont.gov/rules-policies/health-care-rules/health-care-administrative-rules-hcar/adopted-rules
https://humanservices.vermont.gov/rules-policies/health-care-rules/health-care-administrative-rules-hcar/adopted-rules
Page 21: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,
Page 22: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,
Page 23: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,
Page 24: Vermont Medicaid Durable Medical Equipment …criteria/durable-medical-equipment. See Medicaid Covered Services and Health Care Administrative Rules: 4.209 Durable Medical Equipment,

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