Durable Medical Equipment (DME) Prior Authorization (PA) Criteria Sheet Updated, CR 138799

Apr 06, 2026

Effective April 1, 2026, providers can find the Group 1 Support Surfaces Nonpowered Mattresses PA criteria sheet by logging into the Health PAS Online Portal and following this pathway: MaineCare Information > Manual, Forms, and Criteria Sheets.

Providers must complete and attach this criteria sheet when requesting a PA for the following medical equipment: attach this sheet when requesting a PA for the following medical equipment:

Billing Code	Code Description
E0181	Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty
E0184	Dry pressure mattress
E0185	Gel or gel-like pressure pad for mattress, standard mattress length and width
E0186	Air pressure mattress
E0188	Synthetic sheepskin pad
E0189	Lambswool sheepskin pad, any size
E0196	Gel pressure mattress
E0197	Air pressure pad for mattress, standard mattress length and width
E0198	Water pressure pad for mattress, standard mattress length and width
E0199	Dry pressure pad for mattress, standard mattress length and width

 

For questions regarding MaineCare Benefits Manual, Chapter II, Section 60 DME, or this PA criteria sheet change, please contact Shannon Beggs, Provider Relations Specialist.