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DME Covered Services

1. Equipment Supplies HCPCS Code Range S5185 e Electronic medication dispenser e Pillbox timer e Vibrating pillbox timers e Video medication reminder Indications Limitations A determination that the client may be non compliant due to one or more of the following factors e Complex drug regimen e Forgetfulness e Sensory deficit e Lack of understanding e Lack of supervision e Inability to self medicate Documentation that non compliance has resulted in the following conditions due to INAPPROPRIATE use of medication e Relapse into illness e Under utilization of medications e Ineffective drug therapy e Over dosage e Hospitalization e Varying drug levels leading to unpredictable therapeutic results Not covered for residents of skilled nursing facilities Documentation e Written Order or Certificate of Medical Necessity or letter of medical necessity or medical records to document that client meets established criteria above Prior Authorization Required Medical Supplies and Equipment Covered Services and Limitations Module NEBULIZERS and COMPRESSORS Covered to administer aerosol therapy when use of a metered dose inhaler is not adequate or appropriate Equipment Supplies HCPCS Code Range E0570 E0585 E0565 E0570 K0738 Prior Auth Required Includes but is not limited to e Nebulizers e Compressors Indications Limitations Client must meet one of the following e Client s ability to breathe i
2. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30 reduction in thoracoabdominal movement or airflow as compared to baseline and with at least a 4 oxygen desaturation Equipment Supplies HCPCS Code Range E0601 A7030 A7044 Continuous positive airway pressure devices CPAP auto titration A PAP bi level positive airway pressure devices BiPAP S or BiPAP ST nasal applications filters tubing headgear and chin strap Combination oral nasal masks A7029 should be used when billing for combination oral nasal masks Supplies and accessories such as humidifiers masks filters tubing headgear and chin straps are covered as replacement for client owned systems and CANNOT be billed in addition to rental equipment The following codes may be used when billing for replacement accessories e A7028 Oral cushion for combination oral nasal mask replacement only each e A7029 Nasal pillows for combination oral mask replacement only pair Indications Limitations Adult Qualification Criteria Includes 1 Diagnosis of obstructive sleep apnea 2 One or more of the following conditions must be present e Excessive daytime sleepiness e Snoring Medical Supplies and Equipment Covered Services and Limitations Module e Observed apnea or choking episodes 3 Additional Indications symptoms that may follow or be worsened by sleep disordered breathing e Headaches upon awakening e Hear
3. Iloprost also known as Ventavis is a prescription medication for adults with certain kinds of severe pulmonary hypertension It is used to improve exercise ability and symptoms for a brief time Equipment Supplies HCPCS Code Range K0730 Includes the following e Nebulizers e Compressors e Tloprost Inhalation Solution e Mouth piece e Filters e Tubing Accessories and supplies are covered as replacement for use with client owned systems and CANNOT be billed in addition to rental equipment Distilled water is NOT covered Indications Limitations e Client diagnosed 416 0 Primary Pulmonary Hypertension OR 416 8 Other Chronic Pulmonary Heart Disease AND pulmonary hypertension is not secondary to pulmonary venous hypertension e g left sided atrial or ventricular disease left sided valvular heart disease or disorders of the respiratory system e g chronic obstructive pulmonary disease alveolar hypoventilation disorders AND e Client has primary pulmonary hypertension or pulmonary hypertension which is secondary to one of the following conditions connective tissue disease thrombo embolic disease of the pulmonary arteries human immunodeficiency virus HIV infection cirrhosis diet drugs congenital left to right shunts etc AND e The following criteria 1 4 must be met 1 Pulmonary hypertension has progressed despite maximal medical and or surgical treatment of the identified condition AND 2 Mean pulmonary artery p
4. e Click on Try our procedure code search here e Enter the code and search Prior Authorization Wyoming Medicaid requires prior authorization for some medical services and supplies KePRO has been contracted by Wyoming Medicaid to provide medical necessity reviews for prior authorization of DME To obtain prior authorization submit the KePRO Prior Authorization form and all required documentation to KePRO Contact KePRO at e Phone 855 294 1196 o Staffed 6 am to 5 pm MST Monday Friday e Fax 855 294 1197 e Mailing Address KePRO Attention KePRO WYDOH 2810 North Parham Rd Suite 305 Henrico VA 23294 The Prior Authorization PA form and Certificates of Medical Necessity CMN forms are available on the KePRO website at http wydoh kepro com or the Xerox Wyoming Medicaid website at http wyequalitycare acs inc com You can also link to them from the FORMS section of this manual Denied Prior Authorization Reconsideration Process Prior Authorization requests can be denied for two basic reasons Administrative reasons such as incomplete or missing forms and documentation etc or the client does not meet the established criteria for coverage of the item Medical Supplies and Equipment Covered Services and Limitations Module Following a denial for administrative reasons the client the DME provider or the Physician may send additional information in order to request that the decision be reconsidered If
5. s ability to perform functional activities A customized fabricated back module for Orthosis seating may be considered medically necessary when all of the following criteria are met e The client is expected to be in the wheelchair at least 6 hours day and e The client s need for prolonged sitting tolerance postural support to permit functional activities or pressure reduction cannot be met adequately by a seating system lap tray and or prefabricated spinal orthosis and e The client has a significant fixed spinal deformity and or severe weakness of the trunk muscles Seating Systems may only be replaced on a five year basis unless there are extenuating circumstances such as e Client has grown more than expected e A change in the client s physical condition e Extensive wear of the current seating system Documentation must include e Completion of the Wheelchair Certificate of Medical Necessity form e A seating assessment or evaluation by a physician rehabilitative specialist physical therapist or occupational therapist or a qualified technician A qualified technician is an ATP Assistive Technology Practitioners certified thru RESNA or RTS and CRTS Certified Rehab Technology Supplier certified thru NRRTS Please refer to the policy on Repairs Labor Maintenance for further information on documentation and prior authorization requirements for evaluations Medical Supplies amp Equipment Covered Services and Limit
6. Nutrition Therapy Provider Guidelines Providers must be enrolled as retail pharmacy providers and as medical supply DME providers to be eligible for reimbursement for any legend nutrition therapy mainly parenteral Providers must comply with current Wyoming State Board of Pharmacy rules and regulations Providers are required to verify client eligibility Maintain required documentation and coordinate with other healthcare providers involved in the client s care Providers must provide education to include instructions and demonstrations in aseptic technique and appropriate storage methods for solution Providers must document that the above requirements and education standards have been met before providing enteral parenteral therapy Clients or their family who administer the enteral or parenteral therapy must Be trainable and able to maintain the appropriate procedures needed in the home setting Provide a clean and safe environment in which to administer therapy Demonstrate appropriate disposal of hazardous solutions intravenous administration supplies and substances Be able to properly dispose of controlled substances in the home Have documentation stating the client has the ability to perform independent administration Medical Supplies amp Equipment Covered Services and Limitations Module Parenteral nutrition is separately reimbursable in addition to the nursing facility per diem if the client meets the requirements Ente
7. The following forms should be used for documentation purposes Please refer to each DME item s coverage policy for specific documentation requirements that apply e PA Request Form DME http wyequalitycare acs inc com forms KePRO W YDOH DME PA FAX FORM pdf e Medical Necessity Form http wyequalitycare acs inc com forms medical_ nec pdf e Wheelchair Necessity http wyequalitycare acs inc com forms wheelchair_nec pdf e Electric Breast Pump CMN http wyequalitycare acs inc com forms Electric_Breast_Pump CMN_1 22 14 pdf e Parenteral Nutrition Necessity http wyequalitycare acs inc com forms parenteral_nut pdf e DME Mileage Verification Form http wyequalitycare acs inc com forms DME_Mileage_Verification_6 20 12 pdf Replacement Replacement DME orthotics and prosthetics owned by the client are covered if there is a change in the client s medical condition wear or loss Replacement required due to abuse misuse or neglect would not be covered When an item is no longer suitable because of growth development or changes to the client s condition the client the provider and Wyoming Medicaid may negotiate a trade in Trade ins are used to reduce charges paid in reimbursement from the Wyoming Medicaid program Rental and Capped Rental Wyoming Medicaid covers rental of DME when submitting claims for rental use the RR modifier along with the appropriate HCPCS code Any codes lacking the RR modifier are perceiv
8. e g chemotherapy severe spasms chronic intractable pain and when an infusion pump is necessary to safely administer medication Also covered for clients with conditions that require the subcutaneous infusion of insulin in the treatment of diabetes Infusion Pump A device whether internal or external used for venous access infusion of medication chemotherapy blood transfusions or nutrition i e enteral pumps parenteral pumps insulin pumps and ambulatory pumps Equipment Supplies HCPCS Code Range E0776 E0791 C1772 C2626 Supplies necessary for effective use and proper functioning of an external infusion pump are covered for use with rental and client owned pumps for clients whose condition meets the criteria for coverage of the pump Services necessary for maintenance of an infusion pump that is in use for an indefinite period of time are covered after the capped rent limit has been reached Providers should bill this maintenance with code 5035 Home Infusion Therapy Routine Service Of Infusion Device ump Maintenance This requires a Prior Authorization Note For billing of medications administered with external infusion pumps see Pharmacy Services Billing Module Please see the HCPCS book for appropriate codes Indications Limitations When considering location for administration of long term infusion home provides an option for many individuals While high tech home care is perceived to have value to patients famili
9. E0483 Volume and negative pressure ventilators Indications Limitations Reimbursement for rental of ventilators includes all back up equipment and accessories necessary for proper functioning and effective use of the device Accessories are payable only as replacement for use with client owned ventilators for clients whose condition meets the criteria for the device The following supplies accessories are covered as replacement for client owned ventilators only and CANNOT be billed with rental equipment e Batteries Chest shell or wrap Documentation e Written Order or Certificate of Medical Necessity or letter of medical necessity or medical records that document o Pertinent lab values e g elevated PaCO2 etc Number and frequency of hospitalizations secondary to respiratory exacerbation or failure Other methods of treatment and why those methods were deemed inappropriate or ineffective Client s social history Number and frequency of intubations History of client having difficulty being weaned from ventilator Episodes and frequency of disabling dyspnea if pertinent Any other pertinent information documenting the necessity of home ventilation OO O O00 0 0 Prior Authorization Required Medical Supplies amp Equipment Covered Services and Limitations Module WALKERS Covered for clients with conditions that impair ambulation and who have a need for greater stability and security than provided by a cane or crutche
10. Necessity for coverage of medical foods signed by dietician and physician please see included sample letter e Detailed dietary plan written by dietician physician e Total number of units requested Please submit all prior authorization requests for Medical Foods to the Division of Healthcare Financing Office of Medicaid fax number 307 777 6964 Medical Supplies and Equipment Covered Services and Limitations Module SAMPLE LETTER FOR MEDICAID COVERAGE OF MEDICAL FOODS To be put on provider s letterhead Date RE client name D O B client date of birth To Whom It May Concern We are writing a letter of medical necessity regarding the treatment of client first name amp last name client name has been under the consultative care of the clinic name He She has an inborn error of metabolism a genetic disorder known as phenylkentonuria PKU ICD 9 270 1 We are writing to request that medical food formula be covered by his her current medical insurance PKU is a lifelong problem that requires a phenylalanine restricted diet and the prescription of special medical foods by a license physician with the support of a registered dietician in order to control the blood phenylalanine level The term medical food formula as defined in section 5 b of the Orphan Drug Act 21 U S C 360ee b 3 is a food which is formulated to be consumed or administered internally under the supervision of a physician and which is intended f
11. Sections 280 1 280 7 Current ACS Protocol Milliman Care Guidelines Ambulatory Care 12th Edition MILLIMAN and CARE GUIDELINES are registered trademarks of Milliman Inc Last Update 2 11 2008 12 26 14 PM Medical Supplies and Equipment Covered Services and Limitations Module BLOOD GLUCOSE MONITORING Covered for clients with diabetes Equipment Supplies HCPCS Code Range A4258 E0607 E2100 E2101 A9276 A9277 Includes but is not limited to glucometers alcohol or peroxide pints alcohol wipes Betadine or iodine wipes test strips batteries and lancets Continuous glucose monitoring systems are covered for select patients Supplies necessary for effective use and proper functioning of a blood glucose monitor are covered for use with rental and client owned monitors for clients whose condition meets the criteria for coverage of the monitor Indications Limitations Client must be physician diagnosed diabetic and e Physician documents that client is capable of being trained to use the particular device prescribed in an appropriate manner In some cases the client may not be able to perform this function but a responsible individual can be trained to use the equipment and monitor the client to ensure that the intended effect is achieved This is permissible if this information is properly documented by the client s physician and e Device is designed for home rather than clinical use Blood glucose monitors with such
12. actual charge or the Fee Schedule amount Some codes are manually priced off of the manufacturer s invoice which must include an explanation of the expected dates of use clearly marked items and units Invoices must be dated within 12 months prior to the date of service being billed If an invoice older than 12 months is used a letter from the provider must be attached to the claim explaining why an older invoice is being used Packing slips or quotes cannot be used as invoices Wyoming Medicaid reimbursement for purchase or rental of medical supplies and equipment shall include but is not limited to e All elements of manufacturer s warranty e All universal equipment servicing as provided to general public e All adjustments and modifications needed by client to make the item useful and functional e Delivery set up and installation of equipment in the home for additional information see the coverage policy for delivery outside the service area e Training and instruction to client or caregiver in the safe sanitary effective and appropriate use of the item and in any necessary servicing and maintenance to be done by the user e Providing client and or caregiver with all manufacturer s instructions servicing manuals and operating guides needed for routine service and operation Medical Supplies amp Equipment Covered Services and Limitations Module Medicare Wyoming Medicaid Dual Coverage Procedures Some clients have dual b
13. each infusion Systemic toxicity or adverse effects of the drug is unavoidable without infusing it at a strictly controlled rate as indicated by the Facts and Comparisons American Medical Association s Drug Evaluations or the U S Pharmacopeia Drug Information Documentation Written Order or Certificate of Medical Necessity or letter of medical necessity or medical records to clearly document that client meets criteria above including Medical history of client Parenteral nutrition solution or medication to be administered quantity frequency and duration Specific route of administration i e Hep lock PICC line central line etc Person who will be administering the medication or nutrition and All other methods attempted and why they were deemed ineffective or inappropriate For routine maintenance of an infusion pump a written order substantiating the need for ongoing long term infusion pump needs and a PA request form documenting the length of time since the last maintenance was performed Additional Information If pump is to be used for chemotherapy e Location of cancer e Specific medication to be given and e Expected outcome If pump is to be used for anti spasmodic drugs e Length and severity of spasms e Minimum six week trial documenting that client cannot be maintained on noninvasive methods of spasm control or that these methods have intolerable side effects e Prior to pump placement client must have respo
14. eating a regular diet Medical foods are defined as e Lacking in the compounds which cause complications of the metabolic disorder e Not generally available in grocery stores health food stores or pharmacies e Not used as food by the general population e Not foods covered under the Food Stamps program Providers must use procedure codes 9434 or 9435 when submitting claims for medical foods Procedure codes 9434 and 9435 will require prior authorization Wyoming Medicaid will only pay for food with nutritional value The following will be excluded from coverage Foods with Minimal Nutritional Value Cakes Cake mixes Candy Candy covered Chips items Chocolate Chocolate Cookies Cookie dough Dessert items covered items Gum Onion rings Pies Foods described as gluten free are not a benefit of the Wyoming Medicaid program For purposes of billing one unit is equal to one package case Providers must dispense the most cost effective product in accordance with a prescription from a licensed physician Quantity of food billed must be substantiated by a dietician s meal plan Medical Supplies amp Equipment Covered Services and Limitations Module Documentation Prior Authorization Requirements Providers requesting medical foods must be enrolled as a Wyoming Medicaid DME provider The following must be included with any prior authorization requests for Medical Food e Written order e Letter of Medical
15. features as voice synthesizers automatic timers and specially designed arrangements of supplies and materials to enable clients with visual impairments to use the equipment without assistance are covered when the following conditions are met e Client and device meet the three conditions listed above for coverage of standard blood e glucose monitors and e Client s physician certifies that client has a visual impairment severe enough to require use of this special monitoring system Continuous glucose monitoring systems are only covered for adults with type 1 diabetes who have not achieved adequate glycemic control despite frequent self monitoring of fingerstick blood glucose levels especially patients with hypoglycemia unawareness Continuous glucose monitoring systems require prior authorization Documentation Written Order For Continuous glucose monitoring system documentation required includes Written order or CMN Medical Supplies amp Equipment Covered Services and Limitations Module Medical records that document that the client meets the above criteria including records of fingerstick results Prior Authorization Required only for continuous glucose monitoring system Medical Supplies and Equipment Covered Services and Limitations Module BLOOD PRESSURE MONITORS Covered for clients with hypertension whose condition must be self monitored at home An electronic blood pressure monitor is covered only if the client is unable
16. is required for all requests for prior authorization of power wheelchairs power wheelchair options amp accessories Documentation must be provided by using the form and be reviewed and signed by a physician involved in the client s care An evaluation of the client s wheelchair needs by a physician licensed physical or occupational therapist or a qualified technician is required A qualified technician is an ATP Assistive Technology Practitioners certified thru RESNA or RTS and CRTS Certified Rehab Technology Supplier certified thru NRRTS Please refer to the policy on Repairs Labor Maintenance for further information on documentation and prior authorization requirements for evaluations e In addition if a customized wheelchair is prescribed for nursing facility clients the physician must include a statement describing the rehabilitation potential and how the customized wheelchair will enhance the prognosis A written discharge plan stating the planned date of discharge to home or to a non nursing facility setting must accompany the request for the wheelchair Medical Supplies amp Equipment Covered Services and Limitations Module Prior Authorization e Required for rental and purchase of power wheelchairs and power wheelchair options accessories and repairs e Required for seat and back cushions with codes E2609 E2625 e Required for Ultralight manual wheelchairs e Not required for other manual wheelchai
17. joystick o Tilter with finger controls o Other Y4 An evaluation refer to the repair labor policy of the client s wheelchair needs is required and includes Justification for type of POV as well as any options or accessories Evidence of coordinated assessment which includes communication between client caregiver s physician physical and or occupational therapist and equipment supplier Assessment should address physical functional and cognitive issues as well as accessibility appropriateness of use in home able to maneuver around home ability to transport POV and cost effectiveness of equipment Credentials and signature or evaluator Medical Supplies amp Equipment Covered Services and Limitations Module Prior Authorization Required Milliman Care Guidelines Ambulatory Care 12th Edition Copyright 1996 1997 1999 2001 2002 2005 2006 2007 2008 Milliman Care Guidelines LLC All Rights Reserved Copyright strictly enforced Current ACS protocol Medical Supplies and Equipment Covered Services and Limitations Module VENTILATORS Ventilators are covered for rental when necessary in the treatment of neuromuscular diseases thoracic restrictive diseases chronic respiratory failure consequent to chronic obstructive pulmonary disease and respiratory paralysis Ventilators are exempt from the capped rental policy that applies to most other medical equipment rental Equipment Supplies HCPCS Code Range E0450
18. or o Other risk factors for fusion failure are present including gross obesity degenerative osteoarthritis current smoking previous fusion surgery or gross instability or o Any other condition where it is determined after medical review that electrical stimulation is likely to avoid the need for open reduction and bone graft The following indications are non covered Medical Supplies amp Equipment Covered Services and Limitations Module e Ultrasonic osteogenesis stimulation of fractures failed fusions or non unions of the axial skeleton skull and vertebrae e Stress fractures e Pathological fractures due to malignancy unless the neoplasm is in remission e Avascular necrosis of the femoral head Consider direct current stimulation experimental and investigational for all other indications including the treatment of Charcot foot avascular necrosis of the hip and fractures of the scapula or pelvis because of a lack of adequate evidence of its effectiveness for these conditions Documentation e Written or Certificate of Medical Necessity e A detailed record of the item s provided to include brand name model number quantity and date of delivery e A minimum of two sets of radiographs obtained prior to starting treatment with the osteogenesis stimulator separated by a minimum of 90 days Each radiograph must include multiple views of the fracture site accompanied with a written interpretation by a physician stating that t
19. overlay and e Anticipated length of need is at least one year or e Bottoming out is anticipated on a comparable pad overlay Bottoming out is the finding that the client s body will be in contact with a flat outstretched hand palm up that is placed underneath the support surface in various body positions Powered mattress pads overlays except alternating pressure pads are not reimbursable Supplies accessories are covered as replacement for client owned alternating pressure pads only and CANNOT be billed in addition to rental equipment Medical Supplies amp Equipment Covered Services and Limitations Module Documentation e Written Order or Certificate of Medical Necessity or letter of medical necessity or medical records to document O O Other conservative methods of treatment tried the length of time of each and why those treatments were deemed inappropriate or ineffective Has one or more Stage III or IV decubitus ulcers pressure sores or related conditions or is highly susceptible to decubitus ulcers or has a condition of fragile skin integrity or a history of skin ulcers or insult to skin or integrity or Has multiple Stage II decubitus ulcers on trunk or pelvis which have been unresponsive to a comprehensive treatment for at least 30 days using a lesser support surface or Has myocutaneous flap or skin graft for pressure ulcer on the trunk or pelvis within the past 60 days or Is bedridden or chair bo
20. plastic custom e Polishing resurfacing of ocular prosthesis e Enlargement of ocular prosthesis e Reduction of ocular prosthesis e Scleral cover shell e Fabrication and fitting of ocular conformer e Prosthetic eye other type Indications Limitations One enlargement or reduction of the prosthesis is covered without documentation Additional enlargements or reductions are rarely medically necessary and are covered only when information in the medical record supports the medical necessity Replacement of an ocular prosthesis before five years is covered if the prosthesis is irreparably damaged lost or stolen Documentation Written Order Prior Authorization Not Required References www medicare gov Medical Supplies and Equipment Covered Services and Limitations Module GAIT TRAINERS This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease illness or condition Each person s unique clinical circumstances may warrant individual consideration based on review of applicable medical records Rental Purchase Purchase Definition Gait Trainer is a term used to describe certain devices types of walkers that are used to support a client during ambulation Examples Mobility devices other than standard walkers including those with trunk support HCPCS Codes this is not an all inclusive list A4636 A4637 A9270 A9900 E0130 E0135 E0140 E0141 E0143 E014
21. section do not include surgically implanted prosthesis The devices in this section are considered as base or basic devices and may be modified by listing devices from the additions section and adding them to the base procedure Exception A test socket is not medically necessary for an immediate prosthesis No more than two of the same socket inserts are allowed per individual prosthesis at the same time Repair Replacement Socket replacements are covered when medically necessary Documentation of medical necessity includes but is not limited to functional and or physiological needs such as changes in residual limb functional need changes irreparable damage or wear tear due to excessive patient weight or prosthetic demands of very active amputees Prosthetic services include repair or replacement of prosthetic devices other than dental Replacement of usable appliances or artificial limbs may be required because of a change in the client s physical condition Wyoming Medicaid will reimburse for repairs and adjustment of appliances when necessary even when the appliance had been in use before the client became eligible for Wyoming Medicaid Adjustments and repairs of prostheses and prosthetic components are covered under the original order Claims involving the replacement of a prosthesis or major component foot ankle knee socket must be supported by a new physician s order Prosthetist must retain documentation of th
22. to use a standard cuff and stethoscope due to conditions such as poor eyesight or hearing arthritis or other physical disability Equipment Supplies HCPCS Code Range A4660 A4670 Includes but is not limited to Sphygmomanometer blood pressure apparatus with cuff and stethoscope automatic blood pressure monitor and cuff Indications Limitations Blood pressure monitors required for renal dialysis are payable ONLY to approved renal dialysis facilities See Dialysis Equipment and Supplies Documentation Written Order Prior Authorization Not Required Reference Wyoming Medicaid update to website 7 2008 Medical Supplies amp Equipment Covered Services and Limitations Module BREAST PROSTHESES Covered for clients who have had mastectomy Equipment Supplies HCPCS Code Range L8000 L8035 L8600 Includes but is not limited to all breast prostheses such as mastectomy bra mastectomy sleeve mastectomy form and silicone or equal Indications Limitations N A Documentation Written Order Prior Authorization Not Required Medical Supplies and Equipment Covered Services and Limitations Module BREAST PUMPS Breast pumps are not covered for convenience of the mother Manual or standard grade electric breast pumps E0602 or E0603 are covered as a purchase Heavy duty hospital grade breast pumps E0604 are available for short term rental only when Certification of Medical Necessity is supplied by the prescribing phys
23. 4 E0147 E0148 E0149 E0154 E0155 E0156 E0157 E0158 E0159 E1399 Criteria Gait trainers are billed using one of the codes for walkers The client is unable to ambulate independently with a standard front or reverse walker because of the need for postural support due to a chronic neurological condition including abnormal movement patterns poor balance poor endurance or other clearly documented reasons The anticipated functional benefits of walking are not attainable with the use of a standard walker Must demonstrate tolerance for standing and weight bearing through the lower extremities Used in the home and or community by the individual without significant assistance by another individual The medical necessity for a walker with an enclosed frame E0144 compared to a standard folding wheeled walker E0143 has not been established Therefore if the basic coverage criteria for a walker are met and code E0144 is billed payment will be based on the allowance for the least costly medically appropriate alternative E0143 A walker with trunk support E0140 is covered for patients who meet coverage criteria for a standard walker and who have documentation in the medical record justifying the medical necessity for the special features If an E0140 walker is provided and the special features are not justified but the patient does meet the coverage criteria for a standard walker payment will be based on the allowance for the least costly medi
24. A9901 Prior Authorization Not Required All deliveries will be subject to post payment review DME providers must retain documentation that supports medical necessity for all DME equipment Questions and or concerns should be directed to the Xerox Provider Relations Call Center at 307 772 8401 or toll free at 800 251 1268 Call Center hours are Monday through Friday from 9am 5pm References Wyoming Medicaid News dated September 2005 CME 1500 Bulletin 05 017 Medical Supplies amp Equipment Covered Services and Limitations Module DIALYSIS EQUIPMENT and SUPPLIES Wyoming Medicaid reimburses for dialysis systems related supplies and equipment only to approved renal dialysis facilities under the Medicare payment methodology Payment CANNOT be made to DME suppliers pharmacies or home health agencies for dialysis systems related supplies and equipment Medical Supplies and Equipment Covered Services and Limitations Module DRESSINGS Covered for clients who require treatment of a wound or surgical incision HCPCS Code Range A4450 A6457 Indications Limitations None Documentation Written order Prior Authorization Not Required Medical Supplies amp Equipment Covered Services and Limitations Module EYE PROSTHESES Covered for clients with absence or shrinkage of eye due to birth defect trauma or surgical removal Equipment Supplies HCPCS Code Range V2623 V2629 Includes but is not limited to e Prosthetic eye
25. B4162 B9000 B9999 Includes but is not limited to e Feeding supply kits e Nasogastric tubing e Enteral formula Indications Limitations Enteral Nutrition Therapy is considered reasonable and necessary for clients with e Functioning gastrointestinal tracts who due to pathology or non function of the structures that normally permit food to reach the digestive tract cannot maintain weight and strength and overall health status When ordered by a physician who has seen the client within 30 days prior to ordering the therapy and has documented that the client cannot receive adequate nutrition by dietary adjustments and or oral supplements enteral therapy may be given by e Nasogastric e Jejunostomy e Gastrostomy tube Enteral therapy is not covered for clients whose nutritional deficiencies are due to a lack of appetite or cognitive problem Documentation Written Order Documentation of medical necessity must be kept on file by the provider and made available upon request Prior Authorization Not Required Medical Supplies amp Equipment Covered Services and Limitations Module PARENTERAL NUTRITION THERAPY Covered for clients with severe pathology of the alimentary tract which does not allow absorption of sufficient nutrients to maintain weight strength and general health status Equipment Supplies See also Infusion Pump section Includes but is not limited to HCPCS Code Range B4164 B5000 B9000 B9999 e P
26. Code Range E0747 E0749 E0760 Includes but is not limited to e Osteogenic stimulator electrical noninvasive other than spinal applications e Osteogenic stimulator electrical noninvasive spinal applications e Osteogenic stimulator electrical surgically implanted for purchase only e Osteogenesis stimulator low intensity ultrasound non invasive Indications Limitations Electrical stimulation is considered medically necessary for any of the following indications e Fresh fractures fusions or delayed unions of the shaft diaphysis of the tibia that are open or segmental or e Fresh fractures fusions or delayed unions of the scaphoid carpal avicular e For non unions failed arthrodesis and congenital pseudarthrosis pseudoarthrosis of the appendicular skeleton if there has been no progression of healing for three or more months despite appropriate fracture care e Non unions failed fusions and congenital pseudarthrosis where there is no evidence of progression of healing for three or more months despite appropriate fracture care or delayed unions of fractures or failed arthrodesis at high risk sites i e open or segmental tibial fractures carpal navicular fractures or e Clients at high risk for spinal fusion failure when any of the following criteria is met o One or more failed fusions or o Grade II or worse spondylolisthesis or o A multiple level fusion entailing 3 or more vertebrae e g L3 to L5 L4 to S1 etc
27. ERMITTENT POSITIVE PRESSURE BREATHING N IPPB MACHINES LIFTS MEDICAL FOODS MEDICAL SURGICAL SUPPLIES Y Y Y MEDICATION DISPENSER Automatic NEBULIZERS and COMPRESSORS es es o es es No es No NEUROMUSCULAR ELECTRICAL STIMULATORS NMES NUTRITION THERAPY Enteral or Parenteral ORTHOTICS Required for some codes Refer to code look up at http wyequalitycare acs inc com OSTEOGENESIS STIMULATORS es OSTOMY SUPPLIES No Yes OXIMETERS EARS PULSE OXYGEN and OXYGEN EQUIPMENT PACEMAKER MONITORS SELF CONTAINED Required for purchase of codes E0425 E0435 E0440 PARAFFIN BATH UNITS PORTABLE Medical Supplies amp Equipment Covered Services and Limitations Module MEDICAL SUPPLIES AND EQUIPMENT LIST PA Requirement PEAK FLOW METERS No PERCUSSORS Yes PHOTOTHERAPY SERVICES No PNEUMATIC COMPRESSORS and APPLIANCES No PRESSURE REDUCING SUPPORT SURFACES see also HOSPITAL BEDS AND ACCESSORIES WHEELCHAIRS Manual and Power Required for some codes Refer to code look up at http wyequalitycare acs inc com PROSTHETICS Yes REPAIRS MAINTENANCE LABOR Yes SITZ BATHS No STANDERS STANDING FRAMES Yes SUCTION PUMPS No SUPPORTS No TRACHEOSTOMY CARE SUPPLIES No TRACTION EQUIPMENT Yes TRANSCUTANEOUS ELECTRICAL NERVE No STIMULATORS TENS TRANSFER EQUIPMENT No VEHICLE POWER OPERATED POV Yes VENTILATORS Yes WALKERS No WHEE
28. LCHAIRS Manual amp Power e Power wheelchairs and accessories includes E2300 e Yes e Seat and back cushions including E2609 E2617 E2622 E2623 E2624 and E2625 e Yes e Ultralight manual wheelchair e Other Manual wheelchairs e Yes e Miscellaneous codes such as E1399 and K0108 e No e Wheel lock brake extensions E0961 e Yes e No WHEELCHAIR SEATING SYSTEMS Yes WOUND V A C Yes NOT OTHERWISE CLASSIFIED NOC CODES i e E1399 or K0108 Yes Medical Supplies and Equipment Covered Services and Limitations Module AIR FLUIDIZED AND LOW AIR LOSS BED UNITS See Also HOSPITAL BEDS Constant pressure mattresses or mattress overlays are covered when used to prevent pressure ulcers in high risk client or to promote healing of existing pressure ulcers Constant pressure devices provide conforming support surfaces that distribute body weight over large areas Standard foam mattress alternative foam mattress or mattress overlay i e high specification foam convoluted foam cubed foam other mattresses and overlays using gel fluid fiber or air Equipment Supplies HCPCS Code Range E0193 E0194 Powered air flotation bed low air loss therapy e An air pump or blower which provides both sequential inflation and deflation of the air cells or low interface pressure throughout the mattress e Inflated cell height of air cells through which air being circulated is five inches or more e Height of air chambers proximity of ai
29. Level 4 Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills exhibiting high impact stress or energy levels Typical of the prosthetic demands of the child active adult or athlete Potential functional ability is based on the reasonable expectations of prosthetist and treating physician considering factors including but not limited to e Diagnosed with condition s that require prosthetic devices due to accident injury surgery birth defects or disease process e Client s history including prior prosthetic use if applicable and e Client s current condition including status of residual limb and nature of other medical problems and e Client s desire to ambulate Determination of type of prosthesis to be made by treating physician and or prosthetist based upon functional needs of client Prostheses will be denied as not medically necessary if the patient s potential functional level is 0 If a prosthesis is denied as not medically necessity related additions will also be denied as not medically necessary Exceptions will be considered on a case by case basis and must include additional documentation which justifies medical necessity More than 2 test diagnostic sockets for an individual prosthesis are not medically necessary unless there is documentation in the medical record which justifies the need Medical Supplies and Equipment Covered Services and Limitations Module Devices in this
30. Medical Supplies and Equipment Covered Services and Limitations Module Ss e Wyoming Department INTELLIGENT VALUE MEDICAL SUPPLIES AND EQUIPMENT COVERED SERVICES AND LIMITATIONS MODULE Medical Supplies amp Equipment Covered Services and Limitations Module Medical Supplies and Equipment Covered Services and Limitations Module General Guidelines Provider Participation Provider Responsibilities Coverage Reimbursement Medicare W yoming Medicaid Dual Coverage Procedure Documentation Verbal or Written Order physician prescription Certification of Medical Necessity Written Order vs CMN Recertification of Medical Necessity Medical Records Supplier s Records Forms Replacement Rental and Capped Rental Prior Authorization Denial of Prior Authorization Reconsideration Process Medical Supplies for Nursing Facilities Definitions Medical Supplies and Equipment List Coverage Policies Medical Supplies and Equipment Covered Services and Limitations Module Getting Help When You Need It Agency Name amp Address Phone Number Fax Contact For and Hours KePRO 855 294 1196 855 294 e Prior authorization 1197 requests for 2810 North Parham Rd 6 am 5 pm Durable Medical Suite 305 MST Equipment DME Henrico VA 23294 M F e How to complete PA forms Website e Troubleshooting http wydoh kepro com prior authorization problems Email Wyproviderissues kepro com Xerox St
31. Milliman Care Guidelines Ambulatory Care 12th Edition Medical Supplies and Equipment Covered Services and Limitations Module PHOTOTHERAPY SERVICES Covered on a rental basis for infants with Neonatal hyperbilirubinemia is the infant s sole clinical problem Infant greater than or equal to 37 weeks gestational age and birth weight greater than 2 270 gm 5lbs Infant more than 48 hours old Bilirubin level without hemolysis at initiation of phototherapy after infant reaches 48 hours of age or more is 14 mgs per deciliter or above and Bilirubin level without hemolysis less than two mgs per deciliter Equipment Supplies HCPCS Code Range E0202 Phototherapy bilirubin light with photometer Indications Limitations The following conditions must be met prior to initiation of home phototherapy History and physical assessment conducted by infant s attending physician Newborn discharge exam will suffice if home phototherapy begins immediately upon discharge from the hospital Required laboratory studies must have been performed including CBC blood type on mother and infant direct Coombs and direct Bilirubin level without hemolysis Physician certifies that parent caregiver is capable of administering home phototherapy Parent caregiver has successfully completed training on use of equipment and Equipment must be delivered and set up within four hours of discharge from the hospital or notification of provider whichever is mo
32. O O O 0O 0 Portable oxygen systems alone or to complement a stationary oxygen system may be covered if the client is mobile within the residence Claims submitted for oxygen delivery systems and contents must be billed on a monthly basis Rental reimbursement includes e Concentrator regulator demurrage supplies and accessories e Equipment testing cleaning repair and routine maintenance and e Delivery setup and patient instruction Oxygen therapy is not reimbursable for e Angina pectoris in the absence of hypoxemia e Dyspnea without cor pulmonale or evidence of hypoxemia Medical Supplies amp Equipment Covered Services and Limitations Module e Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities and e Terminal illness that does not affect the lungs Respiratory therapy services are not covered The durable medical equipment benefit provides coverage of oxygen and oxygen equipment but does not include a professional component in the delivery of such services A piped in oxygen system is not considered durable medical equipment for reimbursement purposes and is not reimbursable Gas and liquid oxygen cannot be used together Supplies accessories are covered as replacements for client owned oxygen equipment only and CANNOT be billed with rental equipment The rental fee includes all of the items required to operate the equipment Documentation e Written Order o
33. Or ganization Global Pulse Oximetry Project 2007 Medical Supplies and Equipment Covered Services and Limitations Module OXYGEN and OXYGEN EQUIPMENT Covered on a rental basis for clients with severe hypoxemia in the chronic stable state oxygen concentrators are exempt from capped rental For Wyoming Medicaid purposes severe hypoxemia is defined as a PO2 below 55mmHg or an O2 Saturation of 89 or less Equipment Supplies HCPCS Code Range E0424 E0487 E1353 E1406 Contents may be billed in addition to the oxygen delivery system Oxygen contents are billed on a monthly basis not daily or weekly Includes but is not limited to e Stationary and portable gas systems or liquid systems or e Concentrators e Contents for each system Indications Limitations Oxygen Therapy is reimbursable when e Physician has determined that client suffers from severe lung disease or hypoxia related symptoms that might be expected to improve with oxygen therapy or e Client s blood gas levels or O2 Saturation indicate the need for oxygen therapy Oxygen saturation less than or equal to 88 or PAO2 less than or equal to 55mm Hg 7 3 kPa while patient otherwise clinically stable e Oxygen saturation 89 or PAO2 56 59 Hg 7 5 to 7 9 kPa while patient otherwise clinically stable and any of the following Pulmonary hypertension Cor Pulonale Dependent edema suggestive of heart failure P pulmonale on ECG Hematocrit greater than 55 0 55 Angina O
34. accessories or customization of a wheelchair may be covered in addition to the per diem with appropriate documentation of need Option Accessories_ Wheelchair options accessories are covered when medically necessary for use with a medically necessary rental or client owned wheelchair base to allow the client to perform activities of daily living or to function in the home An option accessory that is beneficial primarily in allowing the client to perform leisure or recreational activities or for the convenience of the client or caregiver is not covered Mounting hardware is covered when it corresponds to appropriate covered options and accessories Reclining back wheelchair frame the angle between the seat and the back of the frame is adjustable between 90 and 180 degrees May include elevating leg rests A reclining back may be manually operated by a caregiver or power operated usually by the wheelchair user Reclining back wheelchair frames are covered for clients who e Have a diagnosed medical condition which impairs their ability to tolerate the fully upright sitting position for significant amounts of time usually greater than two hours e Need to remain in a wheelchair or unable to transfer between wheelchair and bed without assistance for purposes of mobility or other interaction with their environment and e Require frequent significant adjustment of their position in the wheelchair either to change hip angle or their sitt
35. ained in the nutrition management of inborn errors of metabolism Nutrition therapy must also provide a sufficient and balanced intake of other nutrients to avoid nutritional deficiencies Nutrition therapy of PKU solely via protein restriction is not possible because it will result in protein malnutrition calorie deprivation vitamin and mineral deficiency failure to thrive and potentially death Medical Supplies amp Equipment Covered Services and Limitations Module The standard of care for PKU requires the use of the medical food formulas and a phenylalanine restricted diet as well as routine nutrition follow up with a specially trained registered dietician The two primary goals of treatment are 1 To maintain the blood phenylalanine at a level that is not toxic but still allows for normal growth and development 2 To ensure that the individual s overall nutritional requirements are met allowing for normal growth and development and the avoidance of nutritional deficiencies The recommended treatment range of blood phenylalanine levels for individuals with PKU is between 2 and 6mg dL 120 and 360f1 moi L There is good correlation of cognitive function and maintenance of blood phenylalanine levels in this treatment range Elevated blood phenylalanine in patients has been associated with behavior and learning problems which can reverse when the blood levels return to the treatment range Currently indefinite continuation of dietar
36. al need for the technologic or design feature of a given type of ankle e Axial rotation unit covered for clients whose functional level is 2 or above Medical Supplies amp Equipment Covered Services and Limitations Module Stump socks and harnesses including replacements are covered when documentation substantiates that the appliance was in use before the client became eligible for Wyoming Medicaid Indications Limitations Coverage based upon medical necessity and clinical assessment of client rehabilitation potential Client rehabilitation potential based on the following classification levels Level 0 Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility Level 1 Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence Typical of the limited and unlimited household ambulatory Level 2 Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs stairs or uneven surfaces Typical of the limited community ambulatory Level 3 Has the ability or potential for ambulation with variable cadence Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion
37. ame stand Indications Limitations Payment for purchase and rental of traction equipment includes all accessories necessary for proper functioning and effective use of the equipment Accessories are payable only as replacement for use with client owned traction equipment for clients whose condition meets the criteria for the equipment Cervical traction that attach to a headboard or a free standing frame have no proven clinical advantage compared to cervical tractions attached to an over the door mechanism The following supplies accessories are covered replacements for client owned traction equipment only and CANNOT be billed with rental equipment e Cervical head harness halter e Cervical pillow e Pelvic belt harness boot e Extremity belt harness Documentation e Written Order or Certificate of Medical Necessity or letter of medical necessity or medical records to document client condition meets criteria above Prior Authorization Required Reference www medicare gov Medical Supplies and Equipment Covered Services and Limitations Module TRANSCUTANEOUS ELECTRICAL NERVE SIMULATORS TENS Covered for clients with chronic intractable pain that has been present for at least three months and presumed etiology of pain is accepted as responding to TENS therapy and for clients with acute post operative pain Equipment Supplies HCPCS Code Range E0720 E0749 e TENS two and four lead Indications Limitations Transcutaneous ele
38. arenteral Solution e Supply kits Indications Limitations Parenteral therapy is given intravenously when ordered by a physician who has seen the client within 30 days prior to ordering the therapy and has documented that the client cannot receive adequate nutrition by dietary adjustments and or oral supplements or tube enteral nutrition Parenteral therapy is covered for clients who have a condition of the GI tract that prevents absorption of sufficient nutrients and require IV feedings to sustain life Parenteral therapy will not be covered for convenience or when the client s nutritional needs can be met with enteral therapy Nutrition therapy is not covered for clients whose nutritional deficiencies are due to lack of appetite or cognitive problem Documentation Written Order AND Wyoming Medicaid Certificate of Medical Necessity Parenteral Nutrition form Prior Authorization Items in this section do not require PA however DME providers should refer to the policy for infusion pumps as some related equipment and supplies do require Prior Authorization Medical Supplies and Equipment Covered Services and Limitations Module ORTHOTICS Orthotic appliances are covered for the correction or prevention of skeletal deformities i e braces splints etc and post operative or post injury rehabilitation Equipment Supplies HCPCS Code Range E1800 E1840 LO000 L4999 S1040 Orthotic services include e Replacement or re
39. as central hyperventilation and bronchopulmonary dysplasia e Infant with tracheostomy e History of recent vent dependency e Infant born to substance abusing mother e Infant child with severe respiratory complications resulting in periods of apnea Equipment Supplies HCPCS Code Range E0618 E0619 A4556 A4557 Apnea monitor including all supplies accessories and services necessary for proper functioning and effective use of equipment Indications Limitations All supplies accessories and services necessary for proper functioning and effective use of the equipment in the rental fee for the monitor and CANNOT be billed separately Reimbursement for remote alarms and complete parent caregiver training in use of equipment and completion of necessary medical record paperwork will be included in the monitor rental payment Documentation Prior to initiation of home apnea monitoring the following must be met e Letter of medical necessity from attending physician describing criteria for use of apnea monitor including the projected length of time equipment will be needed e Apnea monitor rental exceeding six months requires a physician s narrative report of client progress that must be maintained in the provider s files e Anew progress report is required every two months after the initial six months The report must include o Number of apnea episodes during the previous two month period of use o Tests and results of tests performed during
40. ate Healthcare 1 800 251 1268 307 772 e Bulletin manual LLC 8405 inquiries Provider Relations P O Box 667 Cheyenne WY 82003 0667 Call Center Agents are available 9 5 pm MST M F Touchtone phone required e Claim inquiries e Claim submission problems e Client eligibility e How to complete other Medicaid forms e Payment inquiries e Request Field Representative visit e Training seminar questions e Timely filing inquiries e Verifying validity of procedure codes e Claim void adjustment inquiries e WINASAP training Medical Supplies amp Equipment Covered Services and Limitations Module General Guidelines The purpose of this program is to furnish disposable medical supplies and durable medical equipment to Wyoming Medicaid clients for home use Supplies and equipment must e Be reasonable and necessary for the treatment of illness or injury e Be the most cost effective supply or equipment necessary to meet the patient s medical needs e Enable clients to cost effectively remain outside institutional settings by promoting maintaining or restoring health or e Restore clients to their functional level by minimizing the effects of illness or disabling Condition The HCPCS codes ranges listed in the Medical Supplies and Equipment List are subject to change without notice Please use in conjunction with the HCPCS Level II Provider Participation Wyoming Medicaid enrolls medical supply p
41. ation other prosthetic feet may be covered Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot e External keel SACH foot or single axis ankle foot is covered for clients whose functional level is 1 or above e Flexible keel foot or multiaxial ankle foot is covered for clients whose functional level is 2 or above e Flex foot system energy storing foot multiaxial ankle foot dynamic response flex walk system or equal or shank foot system with vertical loading pylon is covered for clients whose functional level is 3 or above KNEES Basic lower extremity prostheses include single axis constant friction knee Based on client functional classification other prosthetic knees may be covered Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of knee e A high activity knee control frame is covered for clients whose functional level is 4 e A fluid pneumatic or electronic knee covered for clients whose functional level is 3 or above e Other knee systems are covered for clients whose functional level is 1 or above ANKLES Basic ankle prostheses include single axis constant friction knee Based on client functional classification other prosthetic ankles may be covered Coverage is extended only if there is sufficient clinical documentation of function
42. ations Module e No more than 2 hours will be allotted for the seating evaluation The evaluation must justify the type of wheelchair seating system and include the evaluator s credentials and signature and measurements of O O O 0O Height amp Weight Seat Width and Depth Hip to Knee Knee to Foot Back Height e Provide evidence of a coordinated assessment that includes communication between the client caregiver s physician physical and or occupational therapist and equipment supplier The assessment should address physical functional and cognitive issues as well as accessibility and cost effectiveness of equipment A seating system may or may not part of a custom wheelchair A wheelchair seating system consists of components used to position the client It is mounted on a mobility base that may be manual or electric The seating system for a child must be fitted to allow for growth Prior Authorization Required for any seating systems References Milliman Care Guidelines Ambulatory Care 12th Edition Copyright 1996 1997 1999 2001 2002 2005 2006 2007 2008 Milliman Care Guidelines LLC All Rights Reserved Copyright strictly enforced Wyoming Medicaid News dated November 21 2003 Wyoming Medicaid News dated July 2005 Medical Bulletin 06 014 Medical Supplies and Equipment Covered Services and Limitations Module WOUND V A C Covered for clients who present with Level III or IV Stage decubitus ulc
43. atrophy such as e Castings or splinting of a limb e Contracture due to scarring of soft tissue as in burn lesions e Hip replacement surgery until orthotic training begins Equipment Supplies HCPCS Code Range E0745 E0762 e Neuromuscular stimulator e Electronic shock unit Indications Limitations Neuromuscular electric stimulators are not covered for treatment of Scoliosis The following supplies accessories are covered as replacement for client owned equipment only and CANNOT be billed in addition to the equipment with rental equipment e Electrodes e Lead wires Documentation Written Order Prior Authorization Not required Medical Supplies and Equipment Covered Services and Limitations Module NUTRITION THERAPY Nutrition therapy is providing essential nutrients vitamins and minerals to meet recommended dietary allowances adequate calories to meet energy requirements and adequate proteins to maintain weight and strength Nutrition therapy is provided in two ways enteral or parenteral Since Parenteral nutrition is not considered DME it does not require prior authorization Equipment Supplies The following medical supplies are covered when used in conjunction with home enteral parenteral therapy and are considered necessary for administration of the therapy IV Poles Parenteral Enteral Pumps Cassettes Administration Kits Dressing Kits Preparation Supplies Pump Supplies Flush Supplies Indications Limitations
44. ause enhancement accessories do not contribute significantly to the therapeutic function of the walker Enhancement accessories may include but are not limited to e Style e Color e Hand operated brakes other than those described in code E0147 or e Basket or equivalent Leg extensions are covered only for clients 6 feet tall or more Payment for purchase and rental of walkers includes all accessories necessary for proper functioning and effective use of the item Medical Supplies and Equipment Covered Services and Limitations Module The following supplies accessories are covered as replacement for client owned walkers only and CANNOT be billed in addition to the equipment with rental equipment e Handgrip e Tip e Platform attachment e Wheels e Leg extensions Indications Limitations Criteria for coverage include e Client is unable to ambulate independently with a standard cane or quad cane because of clearly documented reasons Documentation e Written Order or Certificate of Medical Necessity or a letter of medical necessity or medical records to clearly document the potential benefits to client and indicate the following o Equipment matches client s needs and ability level Prior Authorization Not required References Section 1833 e of the Social Security Act CMS Pub 100 3 Medicare National Coverage Determinations Manual Chapter 1 Section 280 3 Medicare Advantage Medical Policy Bulletin Section DME N
45. cally appropriate alternative Medical Supplies amp Equipment Covered Services and Limitations Module Documentation e An order for each item billed must be signed and dated by the treating physician e Potential benefits to the individual of assisted walking must be clearly documented as follows Q O O The client must be involved in a therapy program established by a physical therapist The program must include measurable documented objectives and functional goals related to the client and equipment that includes a written carry over plan to be utilized by the client and or caregiver The equipment must match the user s needs and ability level The client has had a trial of the requested gait trainer GT and the client shows compliance willingness and ability to use the GT in the home Provide a picture of the requested gait trainer which clearly depicts the type of gait training device and any accessories Indications Need to be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member part Prior Authorization Required References Section 1833 e of the Social Security Act CMS Pub 100 3 Medicare National Coverage Determinations Manual Chapter 1 Section 280 3 Medicare Advantage Medical Policy Bulletin Section DME Number E 76 Topic Walkers Issue Date 12 31 07 Effective Date 1 1 08 Medical Supplies and Equipment Covered Services and Li
46. can be either a narrative description e g lightweight wheelchair base or a brand name model number e Someone other than the physician may complete the detailed description of the item However the treating physician must review the detailed description signature and date the order to indicate agreement e A new order is required every twelve months or when there is a change in the prescription for supplies A written order is not required when the documentation requirements include a CMN and the CMN on file contains the necessary elements of a written order including a signature and date from the ordering Physician Stamped signatures and dates are not accepted 2 Certification of Medical Necessity A Certificate of Medical Necessity CMN is a customized form or handwritten letter of medical necessity that provides essential information needed to determine if equipment devices or other items are medically necessary When a CMN is on file that contains all the required elements of a written order including the signature of the ordering Physician a separate written order is not necessary A CMN misi be signed and dated by the Practitioner within 60 days of the begin service date in order for CMN to be valid For specific items a CMN is required to support the medical indication s for the prescribed item The Medical Supplies and Equipment List specifies which items require a Wyoming Medicaid specific CMN The original CMN must be
47. cate what documentation must be maintained in the client s file for all equipment and supplies provided to a Wyoming Medicaid client 1 Verbal or Written Order Physician Physician Assistant or Nurse Practitioner order prescription Note References to Physician also include Physician Assistant and or Nurse Practitioner Most DMEPOS items may be dispensed with a physician s verbal order Items that require a written order prior to delivery WOPD include e Support Surfaces e Transcutaneous Nerve Stimulators TENS e Seat Lift Mechanisms e Negative Pressure Wound Therapy NPWT e Power Mobility Devices e Wheelchair Seating DMEPOS Providers Suppliers must document all verbal orders with the following elements e Description of Item e Client Name e Physician Name e Start date of verbal order Medical Supplies and Equipment Covered Services and Limitations Module Written orders are required prior to claim submission for all items or services billed even items dispensed based on verbal order Elements required on all written orders include e Client s Name e Physician s printed name including signature and the date the order is signed Stamped signatures and dates are not accepted e Initial date of need or start date e Estimate of total length of time equipment will be needed in months and years e All options or additional features that will be separately billed or that will require an upgraded code The description
48. ccessories necessary for proper functioning and effective use of the device are included in the rental reimbursement e In home overnight 12 hour or similar oximetry trend studies and other single one time oximetry testing are not covered e Oximeters are manufactured with a wide variance in features each of which impact the cost Therefore medical necessity must be documented for additional features such as OO 0 0 O Extra alarms Additional cables that extend the distance between the probe and readout device Various types of probes i e disposable versus re useable Internal memory Ports to allow printing of recorded data or downloading to a computer this list is not all inclusive Documentation e Written Order or Certificate of Medical Necessity or letter of medical necessity or medical records that document O O O 0O O 0 Client s medical condition that indicates the need for in home use of an oximeter Medical justification for additional features listed above that impact the cost Estimated length of time client will require monitoring and Frequency of monitoring required e g continuous daily etc Monthly report for evaluation and regulation of home oxygen therapy O2 saturation readings by a pulse oximeter may be performed by a provider and reviewed and signed off by the physician The provider must maintain all supporting documentation Prior Authorization Required References World Health
49. ch may include power operated elevation leg rests is covered for clients that meet the criteria for a reclining or tilt in space mechanism and e Have the cognitive and motor ability to operate the required control switch es and e Are routinely in situations e g home community school work etc where caregivers are not available within a reasonable time to manually recline or tilt them as needed Combination power recline tilt in space frames if unavailable in manually operated forms are covered for clients that require both recline and tilt in space features e g lack of necessary passive hip flexion for use of a standard tilt in space or inability to tolerate a significantly greater hip extension angle during sitting Custom Wheelchair Uniquely constructed or substantially modified for a specific client and is so different from another item used for the same purpose that the two items cannot be grouped together for pricing purposes The assembly of a wheelchair from modular components does not meet the requirement of a custom wheelchair for payment purposes The use of customized options or accessories does not result in the wheelchair being considered customized There must be customization of the frame of the wheelchair for it to be considered customized Additionally for nursing facility clients the item must be needed for discharge Documentation e Written Order e The Wheelchair Certificate of Medical Necessity
50. clients which require positioning of the body in ways not feasible with ordinary bed due to a medical condition Equipment Supplies HCPCS Code Range E0250 E0373 e Fixed height hospital bed manual head and leg elevation adjustments but no height adjustment e Variable height hospital bed manual height adjustment and with manual head and leg elevation adjustments e Semi electric hospital bed manual height adjustment and with electric head and leg elevation adjustments e Total electric hospital bed electric height adjustment and with electric head and leg elevation adjustments e Ordinary bed typically sold as furniture May consist of a frame box spring and mattress and are fixed height and may or may not have head or leg elevation adjustments Fixed covered if one or more of the following criteria are met e Client has medical condition which requires positioning of the body in ways not feasible with an ordinary bed Elevation of the head upper body less than 30 degrees does not usually require the use of a hospital bed or e Client requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain or e Client requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure chronic pulmonary disease or problems with aspiration Pillows or wedges must have been considered and ruled out An attempt must have been made at using pillow
51. ctrical nerve stimulation TENS involves the direct stimulation of nerves by short duration small amplitude electrical pulses designed to provide non pharmacological pain relief Indications include e Post stroke e Rheumatoid arthritis e Chronic leg ulcers e Labor pain e Arthropathy associated with other viral diseases e Rheumatoid arthritis e Oseoarthrosis e Ankylosing spondylitis e Unspecified inflammatory spondylopathy e Lumbosacral spondylosis with no mention of myelopathy e Cervical region pain e Lumbago e Low back pain e Backache e Unspecified vertebrogenic pain syndrome e Myofascial pain syndrome e Neuromuscular pain e Neuralgia e Neuritis e Radiculitis e Pain in limb The following supplies accessories are covered as replacement for client owned equipment only and CANNOT be billed with rental equipment e Electrodes e Lead wires e TENS supplies two lead per month For purchase physician must determine that the client is likely to derive significant therapeutic Medical Supplies amp Equipment Covered Services and Limitations Module benefit from continuous usage of the unit over a long period of time A TENS unit is not covered for acute pain less than three months duration other than post operative pain For acute post operative pain coverage is for no more than one month following the day of surgery f Atrial periodis recommended for at least one month including atrial of different mod
52. d deviations above mean head wide for its length A second cranial remodeling band or helmet is considered medically necessary if the above criteria were met and asymmetry has not resolved after 2 to 4 months Wyoming Medicaid considers the use of cranial orthotics bands or helmets for other indications not listed above to be experimental and investigational This includes but is not limited to the use in infants with synostotic plagiocephaly craniosynostosis who have not had surgical correction Medical Supplies amp Equipment Covered Services and Limitations Module Documentation Written Order amp CMN or other medical records to support client need Prior Authorization Required for some codes Refer to website code look up at http wyequalitycare acs inc com Medical Supplies and Equipment Covered Services and Limitations Module OSTEOGENESIS STIMULATORS Electrical osteogenesis stimulators provide electrical stimulation to augment bone repair Noninvasive electrical stimulators are characterized by an external power source which is attached to a coil or electrodes placed on the skin or on a cast or brace over a fracture or fusion site Ultrasonic osteogenesis stimulators are noninvasive devices that emit low intensity pulsed ultrasound The ultrasound signal is applied to the skin surface at the fracture location via ultrasound conductive coupling gel in order to stimulate fracture healing Equipment Supplies HCPCS
53. dule INTERMITTENT POSITIVE PRESSURE BREATHING PPB MACHINES Covered for clients whose ability to breathe is severely impaired or whose condition or diagnosis indicates the necessity for IPPB therapy Equipment Supplies HCPCS Code Range E0500 e IPPB machine all types e Built in nebulization e Manual or automatic valves e Internal or external power source Payment for rental of an IPPB machine includes all accessories necessary for proper functioning and effective use of the machine Indications Limitations The following supplies accessories are covered as replacement for client owned IPPB machines only and CANNOT be billed in addition to rental equipment e Breathing circuits e Humidifiers Documentation Written Order Prior Authorization Not Required LIFTS Covered for clients who are unable to transition from lying or sitting to standing Equipment Supplies HCPCS Code Range E0621 E0642 Seat lift mechanism Sling or seat patient lift Client lift non electric Hydraulic Hoyer lift with seat or sling Multipositional patient support system Combination sit to stand system pediatric Indications Limitations Seat Lift Mechanisms Seat lift mechanisms meet the definition of medical necessity when ALL of the following criteria are met The individual has severe arthritis of the hip or knee or has a severe neuromuscular disease The seat lift is part of the physician s treatment plan and is prescribed to ef
54. e prosthesis or prosthetic component replaced the reason for replacement and a description of the labor involved irrespective of the time since the prosthesis was provided to the beneficiary Information must be available upon request It is recognized that there are situations where the reason for replacement includes but is not limited to e Changes in the residual limb e Functional need changes e Irreparable damage or wear tear due to excessive patient weight or prosthetic demands of very active amputees When submitting a prosthetic claim the billed code for knees feet and ankles components must be submitted with modifiers KO K4 indicating the expected patient functional level This expectation of functional ability information must be clearly documented and retained in the prosthetist s records The simple entry of a K modifier in those records is not sufficient There must be information about the patient s history and current condition which supports the designation of the functional level by the prosthetist Medical Supplies amp Equipment Covered Services and Limitations Module Documentation e Written Order or Certificate of Medical Necessity or letter of medical necessity listing each component being requested and the codes e History amp Physical including pre amputation level of activity e Medical records that document the client s functional capabilities and expected functional potential including an explanation for t
55. ed as a purchase and the claim is processed as such All rental payments are applied towards the purchase of DME When rental charges equal the amount allowed by Wyoming Medicaid for purchase or at the end of ten months rental the item is considered purchased and the equipment becomes the property of the client for whom it was approved Exceptions exist for equipment associated Medical Supplies amp Equipment Covered Services and Limitations Module with oxygen ventilators and limited other equipment Items in this category are paid on a daily or monthly rental basis not to exceed a certain period of use After the fee schedule amount has been paid for the maximum amount of time no further payment can be made except for maintenance and servicing All per day rentals are capped at one hundred days and all monthly rentals are capped at ten months Wyoming Medicaid does not cover routine maintenance and repairs for rental equipment Purchased DME is the property of the Wyoming Medicaid client for whom it was approved Items subject to capped rental are considered to have been purchased when the capped rental limit has been reached and therefore are considered to be the property of the client In order to verify whether a specific item is allowed as a purchase or a capped rental refer to the code search function on the Xerox Wyoming Medicaid website e http wyequalitycare acs inc com e Click on fee schedule then review accept terms of use
56. edical Necessity or letter of medical necessity f to provide information about when the equipment was originally purchased estimate if not known and any required repairs f toprovide justification of labor exceeding 8 units e For routine maintenance of an infusion pump a written order substantiating the need for ongoing long term infusion pump needs and a PA request form documenting the length of time since the last maintenance was performed Prior Authorization e Required for all labor or repairs e Required for routine maintenance for infusion pumps e Wheelchair repair requires a prior authorization However it is considered acceptable to complete the repairs and submit the PA request the same day that the repairs were already completed e Wheelchair evaluations require prior authorization Medical Supplies and Equipment Covered Services and Limitations Module SITZ BATHS Covered for clients with infection or injury of the perineal area and use of the item is part of the physician ordered planned regimen of treatment in the client s home Equipment Supplies HCPCS Code Range E0160 E0162 e Sitz baths e Sitz bath chairs Documentation Written Order Prior Authorization Not Required Medical Supplies amp Equipment Covered Services and Limitations Module STANDERS STANDING FRAMES Standers and stander programs can aid in digestion increase muscle strength decrease contractures increase bone density and minimize decalc
57. enefits eligibility Providers must accept assignment from Medicare and Wyoming Medicaid co pay deductible as payment in full for services Not all medical supplies are covered by Medicare Always check the Medicare manual for supplies you are providing to a client with dual coverage Ifa DME item or supply is covered by Medicare no prior authorization is required e Ifan item or supply is NOT COVERED by Medicare and it is also an item that requires PA then providers should follow standard PA procedures e If the item or service is one that IS COVERED by Medicare but the client does not meet Medicare criteria then along with all other PA and documentation requirements the provider may be asked to submit a copy of the Medicare ABN Advance Beneficiary Notice that includes the reason the provider has determined that the client does not meet Medicare criteria e If the item or service is one that IS COVERED by Medicare but the provider isn t certain whether the client meets Medicare criteria the provider may request a PA Documentation Specific criteria for Wyoming Medicaid coverage of medical supplies and equipment are outlined in the Medical Supplies and Equipment List In order to be covered by Wyoming Medicaid the client s condition must meet the coverage criteria for the specific item Documentation substantiating the client s condition meets the coverage criteria must be on file with the DME provider The following requirements indi
58. ers including e Diabetic Foot Ulcers e Wounds e Skin grafts Not subject to capped rental Equipment Supplies Code A6550 WOUND CARE SET FOR NEGATIVE PRESSURE WOUND THERAPY ELECTRICAL PUMP INCLUDES ALL SUPPLIES AND ACCESSORIES HCPCS Code Range E2402 e Vacuum assisted closure machine e Canisters e Dressings Indications Limitations Treatment is authorized for no more than one month at a time Contraindications If a client falls into any of the following contraindicated categories listed below V A C treatment is NOT appropriate e Fistulas to organs or body cavities e Presence of greater than 20 necrotic tissue in wound bed e Osteomyelitis e Cancer in the wound margins Wound V A C treatment is reimbursable outside of the per diem for client s residing in a nursing facility If a client is in an acute care setting and must be placed in a nursing facility on a short term basis three months or less while the wound heals the nursing facility will be reimbursed for that period of time providing all other criteria has been met Documentation e Written Order AND e Medical records that document measurement and location of one of the following wound types o Stage III or IV Pressure ulcers Neuropathic diabetic ulcers Venous or arterial insufficiency ulcers Chronic present for at least 30 days Acute O00 0 Medical Supplies amp Equipment Covered Services and Limitations Module o Traumatic o Dehisced
59. es healthcare providers and insurers this technology may trigger some levels of anxiety Recognizing physical and psychological limitations and environmental barriers measures can be taken to ensure appropriate and successful use of technology in the home A team consisting of the patient physician nurse and pharmacist must work together to ensure that all the required elements are in place With proper education support and oversight home infusions can be safely managed by the patient a family member a health care professional or a designated caregiver When pump is to be used for infusing of medication the following criteria must be met 1 2 and Medical Supplies amp Equipment Covered Services and Limitations Module 3 or 1 4 and 5 m Parenteral administration of medication in the home is reasonable and necessary The drug is administered by a prolonged infusion of at least 4 hours because of proven improved clinical efficiency Therapeutic regimen is proven or generally accepted to have significant advantages over e intermittent bolus administration regimens e infusions lasting less than eight hours or e when pump is used for infusion of medications such as antibiotics or steroids which require an intermittent syringe pump Drug is administered by intermittent infusion each episode lasting less than eight hours which does not require the patient to return to the physician s office prior to the beginning of
60. es of stimulation and adjustment of electrodes f Severaltherapy sessions are needed toestablish the mosteffective stimulation parameters Documentation e Written Order AND e Documentation of chronic intractable pain must also include the following O O A trial period of at least one month but not to exceed two months Trial period may not begin sooner than the three months or used to establish the existence of chronic pain The trial period must be monitored by the physician to determine effectiveness of the TENS unit in modulating the pain The physician s record must document a re evaluation at the end of the trial period and must indicate how often the client used the TENS unit the typical duration of use each time and the results Location and duration of time client has had the pain Other appropriate treatment modalities that have been attempted and why they were deemed inappropriate or ineffective this is to include any medication name and dosage duration and results of treatment If a four lead TENS unit is ordered the medical record must document why a two lead TENS is insufficient to meet the client s needs Prior Authorization Not Required Reference Hayes Inc Medical Supplies and Equipment Covered Services and Limitations Module TRANSFER EQUIPMENT Covered for clients that require assistance with transfer Equipment Supplies HCPCS Code Range E0705 e Transfer board e Transfer device Documentat
61. f the following e Fixed e Reclining e Tilt in space e Standing e Variable seat height Postural support including ANY ONE of the following e No additional postural support e Collateral support e Scoliosis support e Kyphosis support e Lumbar support e Safety belts or strap Head support including ANY ONE of the following e Flat head rest e Winged head rest e Head wedge e Lateral head support e Occipital head rest e Head sling for hydrocephalus e Head strap Medical Supplies amp Equipment Covered Services and Limitations Module Arm rests ANY ONE of the following e Swing away e Full length e Desk length e Fixed e Adjustable height Leg rests including ANY ONE of the following e Removable e Swing away e Fixed e Elevating Battery including ANY ONE of the following e Gel cell e Lead acid wet cell e Sealed lead acid Wheel drive including ANY ONE of the following e Front e Mid or center e Rear e One arm drive e Hand rims e Wheel locks Tires and casters including ANY ONE of the following e Pneumatic e Foam filled e Solid e Anti tippers Control system including ANY ONE of the following e Joystick e Breath control i e sip and puff0 e Visual scanning e Head control e Chin control e Switches for patient without use of hands but able to control other anatomic sites e Tray e Safety vest Ancillary features such as e Tilt in space Medical Supplies and Equipment Covered Services and Limitation
62. f the functional limitations e Other therapeutic interventions and results e Past experience with related items Wyoming Medicaid recommends that a copy of the CMN be kept in the client record In cases where the CMN by itself does not provide sufficient documentation of medical necessity there must be additional clinical information in the medical record The physician must also retain a copy of the order or have equivalent information in the record A client s medical record is not limited to the physician s office records They may include hospital or nursing home records and records from other professionals e g nurses physical therapists prosthetist orthotist and dieticians This documentation is not sent to the supplier or Wyoming Medicaid however it may be requested 6 Supplier s Records For purposes of billing Wyoming Medicaid a supplier must maintain patient records which include e Current original physician orders e CMN and additional medical necessity information provided by the physician or required by KePRO or Wyoming Medicaid e Detailed record of item s provided to include brand name model number quantity and proof of delivery e Approved prior authorization and e Documentation supporting the client or caregiver was provided with manufacturer instructions warranty information service manual and operating instructions Medical Supplies and Equipment Covered Services and Limitations Module Forms
63. fect improvement or arrest retard deterioration of the individual s condition The individual is completely incapable of standing up from any chair in their home It is not sufficient justification for a seat lift mechanism if the individual has difficulty rising from a chair or is unable to stand up from a low chair Almost all individuals capable of ambulation are able to rise from an ordinary chair if the seat height is appropriate and the chair has arms Once standing the individual is capable of ambulation Have all appropriate therapeutic modalities to enable the patient to transfer from a chair to a standing position e g medication physical therapy been tried and failed If yes this is documented in the patient s medical records Medically necessary seat lift mechanisms are those devices that operate smoothly can be controlled by the individual and effectively assist the individual in standing up and sitting down without other assistance NOTE For a seat lift mechanism coverage is only allowed for the E0627 Seat Lift Mechanism Incorporated Into A Combination Lift Chair Mechanism Providers should submit the charge for the corresponding recliner chair under code A9270 Non Covered Item Or Service and may balance bill clients for this charge NOTE Vehicle lifts such as those used for transporting scooters power wheelchairs or manual chairs are not covered Medical Supplies amp Equipment Covered Services and Limitation
64. g facility per diem As well all other documentation and medical records requirements stand as noted in each policy If there are questions about this procedure the DME provider should contact KePRO Definitions Medical Supplies and Equipment Covered Services and Limitations Module For purposes of this section the following definitions apply Abuse Intentional damage or destruction of equipment by client Confined to bed Client condition is so severe that client is essentially confined to bed Custom Made for a specific client based according to his her individualized measurements and or patterns substantial adjustments made to prefabricated items by specially trained professionals to meet the needs and or unique shape of individual clients Customized items cannot be appropriately used by other clients due to the individual specific features of said items Disposable Medical Supplies Medical supply or piece of equipment intended for one time use specifically related to the active treatment or therapy of Wyoming Medicaid clients for medical illness or physical condition This does not include personal care items i e deodorants talcum bath powders soaps dentifrices eye washes contact solutions oral or injectable over the counter drugs and medications Durable Medical Equipment DME To qualify for coverage DME must meet all of the following requirements e Must withstand repeated use e Must be primarily and customar
65. he difference if that is the case It is recognized within the functional classification hierarchy that bilateral amputees often cannot be strictly bound by functional level classifications Prior Authorization Required Reference www medicare gov_ Article L11453 Medical Supplies and Equipment Covered Services and Limitations Module REPAIRS MAINTENANCE LABOR Wyoming Medicaid reimburses repairs when e Equipment is still medically necessary for client s e Equipment is no longer under warranty Wyoming Medicaid reimburses labor for certain additional services performed by skilled professionals such as e Replacement of batteries that require the skills of a trained technician such as the battery changes for power wheelchair and scooter batteries e Wheelchair and seating evaluations performed by a qualified technician A qualified technician is an ATP Assistive Technology Practitioners certified thru RESNA or an RTS or CRTS Certified Rehab Technology Supplier certified thru NRRTS Wyoming Medicaid reimburses services necessary for routine maintenance of infusion pumps parenteral and enteral feeding pumps that are in use for an indefinite period of time after the capped rent limit has been reached Equipment Supplies HCPCS Code Range K0739 K0740 S5035 K0739 will be used for Repair or Nonroutine Service for Durable Medical Equipment Other than Oxygen Equipment Requiring the Skill of a Technician Labor Com
66. here has been no clinically significant fracture healing between the two sets of radiographs Prior Authorization Required References Milliman Care Guidelines Electrical Nerve Stimulation Transcutaneous TENS Ambulatory Care 2 Edition ACG A 0241 AC Centers for Medicare and Medicaid Services CMS Decision memo for ultrasound stimulation for nonunion fracture healing CAG 00022R Medicare Coverage Database Baltimore MD CMS April 27 2005 CMS Pub 100 3 Medicare National Coverage Determination Manual Chapter 1 Section 150 2 Medical Supplies and Equipment Covered Services and Limitations Module OSTOMY SUPPLIES Covered for clients with an ostomy Equipment Supplies HCPCS Code Range A4361 A4434 Following are covered if medically necessary for use with ostomy e Skin moisturizers e Protectants e Sealants Indications Limitations None Documentation Written Order Prior Authorization Not Required Medical Supplies amp Equipment Covered Services and Limitations Module OXIMETERS EARS PULSE Covered for clients requiring a minimum of daily monitoring of arterial blood oxygen saturation levels for evaluating and regulating home oxygen therapy Coverage for other indications will be determined on a case by case basis Equipment Supplies HCPCS Code Range E0445 A4606 Oximeter Indications Limitations e Pulse oximetry readings are covered in the monthly fee for concentrators e Supplies and a
67. ician Pumps are rented for a 3 month time frame with re evaluation of need assessed every 3 months Equipment Supplies HCPCS Code Range E0602 E0604 A4281 A4286 May include but is not limited to manual standard grade electric or heavy duty hospital grade breast pump including breast pump starter kit Indicate the RR modifier for rental of heavy duty hospital grade breast pumps Indications Breast pumps are covered under the following conditions 1 Prescribing provider Physician Nurse Practitioner or Physician Assistant certifies that breastfeeding is medically necessary for the infant AND 2 Mother has received education regarding health nutritional immunological developmental psychological social and economic benefits of breastfeeding from the prescribing physician 3 Mother has initiated contact with and plans to receive follow up support from a community breastfeeding program such as WIC La Leche League or the community Public Health Nursing Office or 4 Infant is pre term or low birth weight with increased nutritional needs or Infant requires hospitalization longer than the mother or 6 Infant has diagnosis of cleft palate cleft lip Downs Syndrome cardiac problems Cystic Fibrosis PKU neurological impairment failure to thrive or other conditions that necessitate breastfeeding or 7 Infant has cranial facial abnormalities or is unable to such adequately or 8 Infant has severe feeding problems Nn Accesso
68. ies necessary for proper use and maintenance of equipment and complete client caregiver training are included in the rental purchase reimbursement Reimbursement includes but is not limited to Chest compression vest Chest compression generator and hoses Percussive ventilation system Cough stimulator Percussor Indications Limitations Covered in clients with the following conditions Cystic Fibrosis for clients age 2 years or older when conventional chest physical therapy is not feasible Chronic Obstructive Lung Disease Chronic Bronchitis or Emphysema when client or operator of powered percussor has received appropriate training by a physician or therapist and no one competent to administer manual therapy is available Current diagnosis o V46 0 Dependence on aspirator o V46 1 Dependence on respirator o V46 8 Dependence on enabling machines Percussors are not covered when used for clients less than age 2 Documentation Written Order or Certificate of Medical Necessity or letter of medical necessity or medical records that document o Diagnosis of cystic fibrosis or similar condition that causes an over production of secretions o Other methods of treatment attempted the length of time of each and why they were deemed inappropriate and or ineffective o Client s medical and social history o Caregiver client understanding of use and cleaning of equipment Prior Authorization Required References Hayes Inc
69. ifications Standers are covered for clients with neuromuscular conditions who are unable to stand alone Equipment Supplies e Standers Standing Frames HCPCS Codes E0637 E0638 E0641 E0642 Documentation e Written Order or Certificate of Medical Necessity or letter of medical necessity or medical records to document O 0 Or O O Diagnosis relevant to the requested equipment including functioning level and ambulatory potential Include information about other equipment currently being used by the client Anticipated benefits of the equipment Frequency and amount of time of a standing program Anticipated length of time of a standing program Client s height weight age Anticipated changes in the client s needs anticipated modifications or accessory needs as well as the growth potential of the stander Prior Authorization Required Reference obtained from Texas Medicaid website Medical Supplies and Equipment Covered Services and Limitations Module SUCTION PUMPS Covered for clients who have difficulty raising and clearing secretions secondary to cancer or surgery of the throat or mouth dysfunction of the swallowing muscles unconsciousness or obtunded state or tracheostomy Equipment Supplies HCPCS Code Range E0600 e Suction pump Documentation Written Order Prior Authorization Not Required Medical Supplies amp Equipment Covered Services and Limitations Module SUPPORTS Covered for post surgical c
70. ily used to serve a medical purpose e Must not in general be useful to a person in the absence of illness disability or injury e Must be appropriate for use in the home this does not include an inpatient or nursing facility e Must not be considered experimental or investigational e Must generally be accepted by the medical community e Primary purpose must not be to enhance the personal comfort of the client or provide convenience for the client or care giver Invoice Document which provides proof of purchase and actual cost s for equipment and or supplies to the service provider The lowest price on the invoice including provider discounts will be used to reimburse manually priced items Manufacturer The original producer of equipment components parts supplies or prosthetic devices Medical Necessity or Medically Necessary Medical necessity for disposable medical supplies equipment prosthetic devices which are necessary in the treatment prevention or alleviation of an illness injury condition or disability Determination of medical necessity shall be made in accordance with the following criteria from Wyoming Medicaid Rules Chapter 11 Medical Supplies and Equipment i It is prescribed by a physician or other licensed practitioner Medical Supplies amp Equipment Covered Services and Limitations Module ii It is a reasonable appropriate and effective method for treating the client s illness injury condi
71. ing position relative to the ground Tilt in space wheelchair frame_ the angle between the seat and the back remain relatively fixed but the seat and back pivot as a unit away from the fully upright position such that the angle that both the seat and back make with the ground is able to be adjusted usually more than 30 degrees A tilt in space wheelchair frame may be manually operated by a caregiver or power operated usually by the wheelchair user A tilt in space option is covered if the patient has one or more of the following e High risk for development of a pressure ulcer and is unable to perform a functional weight shift e A medical condition which necessitates changes in position while accomplishing basic activities of daily living where the position changes cannot be performed manually and where reclining is contraindicated because of shear forces to the skin e A medical condition which necessitates changes in position due to severe fatigue or potential for loss of skin integrity AND where timely transfer to a bed to rest is not possible Medical Supplies and Equipment Covered Services and Limitations Module e Note Lower extremity edema is NOT an indication for tilt in space as the legs are not elevated level with or higher than the heart with tilt in space positioning Criteria additions are located in Milliman Care Guidelines Ambulatory Care 12 edition Power operation of the reclining or tilt in space mechanism whi
72. ing used Prior Authorization Not required for standard manual grade Required for heavy duty hospital grade electric breast pumps References Wyoming Medicaid News dated July 2005 Medical Bulletin 05 014 Wyoming Medicaid News dated April 2006 CMS 1500 Bulletin 06 003 Medical Supplies and Equipment Covered Services and Limitations Module CANES AND CRUTCHES Covered for clients with medical condition that causes instability or impairs balance Equipment Supplies HCPCS Code Range E0100 E0105 E0110 E0118 Includes but is not limited to canes walkers pads handgrips and tips Indications Limitations Payment for purchase and rental includes all accessories necessary for proper functioning and effective use of the item Accessories such as tips and handgrips are payable for client owned equipment when the client s condition meets the criteria for coverage of the item Supplies and or accessories CANNOT be billed in addition to rental equipment Documentation Written Order Prior Authorization Not Required Medical Supplies amp Equipment Covered Services and Limitations Module COMMODES CHAIRS Covered for clients confined to bed room or home where without bathroom facilities on floor or bathroom facilities are inaccessible Equipment Supplies HCPCS Code Range E0160 E0175 Includes but is not limited to commode chairs pails and footrests Indications Limitations A commode chair with detachable arms is covered
73. ion Copyright 1996 1997 1999 2001 2002 2005 2006 2007 2008 Milliman Care Guidelines LLC All Rights Reserved Copyright strictly enforced Medical Supplies and Equipment Covered Services and Limitations Module PRESSURE REDUCING SUPPORT SURFACES see also HOSPITAL BEDS AND ACCESSORIES WHEELCHAIRS Manual and Power Covered for clients with or highly susceptible to pressure ulcers and whose physician will be supervising its use in connection with client s course of treatment Equipment Supplies HCPCS Code Range E0181 E0199 Includes but is not limited to e Pressure pads e Dry pressure mattress e Gel pads e Air mattresses e Water pressure mattresses e Sheepskin e Gel mattresses Indications Limitations Covered when the client meets one of the following criteria 1 Complete immobility i e the client cannot make changes in body position without assistance 2 Limited mobility i e the client cannot independently make changes in body position significant enough to alleviate pressure or 3 Any stage pressure ulcer on trunk or pelvis If the client meets criteria 2 or 3 above the client must also meet at least one of the following criteria e Impaired nutritional status e Fecal or urinary incontinence e Altered sensory perception or e Compromised circulatory status Pressure reducing mattress replacements are covered e When client meets the coverage criteria for a pressure reducing mattress pad
74. ion Written Order Prior Authorization Not Required Medical Supplies amp Equipment Covered Services and Limitations Module VEHICLE POWER OPERATED POV Covered for clients diagnosed with medical condition which impairs ability to walk and would otherwise be confined to bed or chair Equipment Supplies HCPCS Code Range K0800 K0802 K0806 K0808 K0812 e Power Operated Vehicle Indications Limitations POV indicated for increasing independence and ability to perform major life functions and or activities that the average person in the general population can perform with little or no difficulty These functions activities include but are not limited to e Caring for oneself e Mobility e Learning e Working e Performing manual tasks e Breathing e Seeing and communicating Criteria for Coverage includes Possessing significant limited limb function and cannot propel manual wheelchair due to any ONE of the following e Absence or deformity of an upper extremity e Inadequate upper extremity strength range of motion or coordination e Inadequate endurance e Decreased cardiopulmonary tolerance Have no means of safe independent mobility Compared to use of a manual wheelchair client s use of POV must result in significant improvement in independent mobility and ability to perform major life activities and No other uncompensated conditions that limit ability to participate in daily activities including significant im
75. ition Copyright 1996 1997 1999 2001 2002 2005 2006 2007 2008 Milliman Care Guidelines LLC All Rights Reserved Copyright strictly enforced ACS protocol NOT OTHERWISE CLASSIFIED NOC CODES Providers may contact Xerox in writing with requests to cover code s All requests must include a complete description of the item including brand product number size etc Use procedure code modifiers when appropriate Documentation e Written Order AND e Other documentation may be requested Prior Authorization Prior authorization is required for rental and purchase of durable medical equipment not otherwise classified
76. ity Covered Services Manual at http wyequalitycare acs inc com manuals Manual_Institutional pdf Exceptions to items that are included in the per diem rate include such specialized items as e Orthotics prosthetics e Ventilators e Customized wheelchairs e Power Wheelchairs and related accessories e Hearing Aids e Repairs to specialized items if due to normal wear and tear and not because of abuse or neglect To verify whether a particular item is included in the SNF per diem reimbursement or whether separate Wyoming Medicaid coverage is allowed refer to the Xerox Wyoming Medicaid website e http wyequalitycare acs inc com e Click on fee schedule then review accept terms of use e Click on Try our procedure code search here e Enter the code and search Medical Supplies amp Equipment Covered Services and Limitations Module In order to secure payment for medical equipment and or supplies outside of the nursing facility per diem the DME provider must obtain prior authorization from KePRO KePRO will determine 1 Whether the requested equipment or supply is considered specialized and allowed as an exception in addition to the nursing facility per diem and if so 2 Whether the requested equipment or supplies are considered medically necessary for the client On the Prior Authorization Form the DME provider must indicate that the request is for prior authorization for equipment and or supplies outside of the nursin
77. kept on file by the supplier A CMN may be faxed to a supplier by a physician and used to file a claim however the supplier must obtain the original CMN All CMN forms are available for downloading on line at http wyequalitycare acs inc com or use the links to the forms contained in the Forms section of this manual 3 Written Order vs CMN When documentation requirements include a CMN and the CMN contains the required elements of a written order including the signature of the ordering Physician it is not necessary to also have a separate written order Any additional information which justifies the medical necessity of the item should also be maintained Medical Supplies amp Equipment Covered Services and Limitations Module 4 Recertification of Medical Necessity Documentation of medical necessity must be updated annually or when physicians estimated quantities frequency or duration of client need has expired whichever occurs first unless otherwise specified in the Medical Supplies and Equipment List of this manual 5 Medical Records Physicians must maintain medical records including sufficient documentation of the client s condition substantiating the need for the items This information includes the client s diagnosis and other pertinent information including but not limited to e Duration of the client s condition e Clinical course worsening or improvement e Prognosis e Nature and extent o
78. lients and clients with intractable edema of the lower extremities or other circulatory disorders Equipment Supplies HCPCS Code Range L3040 L3090 L0120 A6530 A6549 L0970 L0999 A4561 A4562 e Elastic Supports e Elastic Surgical Stockings e Slings e Trusses Indications Limitations e Support pantyhose are NOT covered Documentation Written Order Prior Authorization Not Required Medical Supplies and Equipment Covered Services and Limitations Module TRACHEOSTOMY CARE SUPPLIES Covered for clients with an open surgical tracheostomy Equipment Supplies HCPCS Code Range A4623 A4626 A4628 A4629 A7523 A7526 S8189 e Tracheostomy care or cleaning starter kit covered following an open surgical tracheostomy for a two week post operative period e An artificial larynx is covered for clients that have had a laryngectomy or whose larynx is permanently inoperable Documentation Written Order Prior Authorization Not Required Medical Supplies amp Equipment Covered Services and Limitations Module TRACTION EQUIPMENT Covered for clients with orthopedic impairments requiring traction equipment that prevents a ambulation and meet the following criteria e Client has musculoskeletal or neurological impairment requiring traction equipment e Appropriate use of a home cervical device demonstrated to client and client tolerates device Equipment Supplies HCPCS Code Range E0840 E0948 e Traction frame stand e Fracture fr
79. mitations Module HEAT COLD APPLICATION DEVICES Covered for clients with medical conditions for which the application of heat and cold is therapeutic Equipment Supplies HCPCS Code Range E0200 E0249 Includes but is not limited to e Heating pads moist and dry e Water circulating pumps e Hot water bottles e Ice cap or collar e Pads for water circulating heat units Indications Limitations Supplies accessories are covered as replacement for client owned equipment only and CANNOT be billed in addition to the equipment with rental equipment Documentation Written Order Prior Authorization Not Required Medical Supplies amp Equipment Covered Services and Limitations Module INCONTINENCE APPLIANCES and CARE SUPPLIES Covered for clients who are unable to control bladder or bowel function Equipment Supplies HCPCS Code Range A4310 A5200 Please check the HCPCS book for appropriate codes Indications Limitations Incontinence diapers briefs and liners are not covered for clients under age three limited to 30 day supply which may not include more than 390 diapers briefs Documentation Written Order Prior Authorization Not Required Medical Supplies and Equipment Covered Services and Limitations Module INFUSION PUMPS EXTERNAL and ACCESSORIES Covered for clients with conditions requiring intermittent or continual infusion of medication or nutrition when this form of administration is safe reasonable and necessary
80. n 250 pounds Bed cradles covered when necessary to prevent contact with bed coverings Side rails or safety enclosures covered when required by client s condition and are an integral part of or an accessory to a covered hospital bed Indications Limitations If client does not meet any of the coverage criteria for any type of hospital bed request for bed will be denied as not medically necessary Total Electric Beds not covered as the height adjustment feature is a convenience feature Over bed tables are not covered as they are not primarily medical in nature Replacement innerspring or foam rubber mattresses are covered for client owned hospital bed when medically necessary Documentation e Written Order or Certificate of Medical Necessity or letter of medical necessity or medical records to explain how the client meets the established criteria below O Other conservative methods of treatment have been tried reasons why those treatments were deemed inappropriate or ineffective or O Client has one or more Stage III or IV decubitus ulcers pressure sores or related conditions or is highly susceptible to decubitus ulcers or has a condition of fragile skin integrity or a history of skin ulcers or insult to skin integrity or o Client has multiple Stage II decubitus ulcers on trunk or pelvis which have been unresponsive to a comprehensive treatment for at least 30 days using a lesser support surface or o Clie
81. nded favorably to a trial dose of the intrathecal anti spasmodic medication If pump is to be used for chronic intractable pain e Specific location of pain Medical Supplies and Equipment Covered Services and Limitations Module e Length and severity of pain e Client history indicates adequate response to non invasive methods of pain control including attempts to eliminate physical and behavioral abnormalities which may cause an exaggerated reaction to a drug e Preliminary trial of intraspinal opioid drug administration must be undertaken with temporary intrathecal epidural catheter to substantiate adequately acceptable pain relief and degree of side effects including effects on the activities of daily living and client acceptance 4 If pump is to be used for uncontrolled diabetes e Length of time the client has had condition e Frequency of blood sugar testing and e Client s previous treatment regimen Prior Authorization Required for pump rental and maintenance codes References Milliman Care Guidelines Ambulatory Care 12th Edition Copyright 1996 1997 1999 2001 2002 2005 2006 2007 2008 Milliman Care Guidelines LLC All Rights Reserved Copyright strictly enforced Medical Supplies amp Equipment Covered Services and Limitations Module INHALATION CONTROLLED DOSE DRUG DELIVERY INHALATION SYSTEM Covered for clients for the administration of Iloprost inhalation solution Item is subject to capped rental
82. nge of motion or coordination Inadequate endurance Decreased cardiopulmonary tolerance The client has demonstrated through a trial period with a similar powered wheelchair the ability to safely and independently operates the controls of a power wheelchair the client has no other significant uncompensated conditions that limit ability to participate in daily activities including of ANY ONE of the following AND Vision Cognition Judgment Physical layout surfaces and obstacles of the area in which the motorized wheelchair is to be used permit safe operation of the device Multiple Wheelchairs _ Wyoming Medicaid only covers purchase rental or repair of multiple or duplicate wheelchairs used for the same or similar purposes when substantial documentation of Medical Supplies amp Equipment Covered Services and Limitations Module medical necessity is received Wyoming Medicaid does not cover back up equipment for convenience The provider may supply back up equipment but the provider may not bill Wyoming Medicaid Nursing Facilities Wheelchairs accessories and repairs of personal wheelchairs are always included in the per diem for a resident of a nursing facility However under limited circumstances the customization of a wheelchair may be covered outside the per diem with written prior authorization for the client s permanent and full time use Repairs to or replacement of specialized parts including power wheelchair
83. nt has myocutaneous flap or skin graft for pressure ulcer on the trunk or pelvis within the past 60 days or Medical Supplies amp Equipment Covered Services and Limitations Module O Client is bedridden or chair bound or has limited mobility but cannot independently make changes in body position significant enough to alleviate pressure or o Client is completely immobile and cannot make changes in body position without assistance o Documentation must show client s medical condition which necessitates the manual variable height feature This feature is not reimbursable when it is used convenience of a caregiver e Client must have a care plan established by the physician or other licensed healthcare practitioner directly involved in the client s care that should include the following o Education of client and caregiver on prevention and or management of pressure ulcers Regular assessment by a licensed healthcare practitioner Appropriate turning and positioning Appropriate wound care for Stage IL II or IV ulcer Moisture incontinence control if needed and Nutritional assessment and intervention consistent with the overall plan of care if there is impaired nutritional status O0O000 0 Adherence to care plan treatment is not to be construed as elements for coverage criteria Prior Authorization Required References CMS National Coverage Policy CMS Pub 100 3 Medicare National Coverage Determinations Manual Chapter 1
84. ntal long term benefit was lacking CPM did not enable an earlier return to normal shoes Documentation Written Order from physician with letter of medical necessity to explain length of need if device is to be used longer than 21 days Prior Authorization Required References Milliman Care Guidelines Ambulatory Care 12th Edition Copyright 1996 1997 1999 2001 2002 2005 2006 2007 2008 Milliman Care Guidelines LLC All Rights Reserved Copyright strictly enforced MILLIMAN and CARE GUIDELINES are registered trademarks of Milliman Inc Last Updated 2 11 08 12 16pm Medical Supplies amp Equipment Covered Services and Limitations Module C PAP BI PAP MACHINE This item subject to capped rental and covered for clients diagnosed with mild to moderate or severe obstructive sleep apnea and for whom surgical intervention may be a likely alternative Intermittent assistive devices BiPAP S or BiPAP ST and C PAP are covered and are reimbursable for skilled nursing facility clients C PAP BI PAP MACHINES initiate positive pressure therapy in clients with obstructive sleep apnea OSA or other respiratory difficulties AHI is equal to the average number of episodes of apnea and hypopnea per hour and must be based on a minimum of 2 hours of sleep recorded by polysomnography using actual recorded hours of sleep AHI may not be extrapolated or projected Apnea is defined as a cessation of airflow for at least 10 seconds
85. only if documentation supports medical necessity in cases such as obesity paraplegia etc Payment for purchase and rental of a commode includes all accessories necessary for proper functioning and effective use of the commode Accessories such as a commode pail or pan are payable only as replacement for use with client owned commodes whose condition meets the criteria for coverage Supplies accessories CANNOT be billed in addition to rental equipment ACTIVITY CHAIRS ARE NOT COVERED CHAIRS Documentation Written Order Prior Authorization Not required for most commodes but is required for E0170 Purchase Only Medical Supplies and Equipment Covered Services and Limitations Module CONTINUOUS PASSIVE MOTION CPM DEVICES Covered for clients who have had surgical knee replacement or arthroplasty Equipment Supplies HCPCS Code Range E0936 Payment for rental includes all accessories necessary for proper functioning and effective use of the device Indications Limitations e Use of CPM device must begin within 2 days following surgery e Coverage is limited to 10 days 21 days following knee replacement arthroplasty when device is used in client s home Role of CPM in long term benefit for elbow and shoulder surgeries remains uncertain for hallux valgus and bunions a systematic review suggested that using CPM appeared to improve range of motion and provide somewhat earlier post bunionectomy recovery however evidence of increme
86. or the specific dietary management of a disease or condition for which distinctive nutritional requirements based on recognized scientific principles are established by medical evaluation PKU results from a deficiency of the enzyme responsible for metabolizing the amino acid phenylalanine This results in the build up of phenylalanine to toxic levels An untreated child with PKU will suffer irreversible brain damage as well as severe and progressive neurological disorders Normal growth and development are possible if an infant with PKU is treated appropriately In adolescents and adults neurological deterioration phobias difficulty in concentration and impulse control and loss of IQ points can occur if treatment is not sustained Patients are treated with prescribed medical foods formulas in a variety of forms powder capsule liquid bar etc special low protein modified food products as well as a phenylalanine restricted diet This diet excludes all foods high in protein i e meat poultry fish dairy nuts and legumes and markedly restricts all grains including rice breads and pastas Currently patient name is prescribed name of medical formula which is a medical formula used to manage PKU Medical foods formulas provide the primary protein constituent 80 85 of RDA protein for the PKU dietary treatment regimen Use of these products is medically supervised by a physician and implemented by a registered dietician specially tr
87. ot limited to e Pacemaker monitor self contained checks battery depletion includes audible and visible check systems e Pacemaker monitor self contained checks battery depletion and other pacemaker components includes digital visible check systems Documentation Written Order Prior Authorization Not Required Medical Supplies amp Equipment Covered Services and Limitations Module PARAFFIN BATH UNITS PORTABLE Covered for clients with conditions that are expected to be relieved by long term use of this modality and who have undergone a successful trial period of paraffin therapy Equipment Supplies HCPCS Code Range A4265 E0235 Includes but is not limited to e Portable paraffin bath units e Paraffin covered for use with rental and client owned paraffin bath units for clients whose condition meets the criteria for coverage of the device Documentation Written Order Prior Authorization Not Required Medical Supplies and Equipment Covered Services and Limitations Module PEAK FLOW METERS Covered for clients with chronic asthma Equipment Supplies HCPCS Code Range S8110 S8096 Includes but is not limited to Hand held peak expiratory flow rate meters Documentation Written Order Prior Authorization Not Required Medical Supplies amp Equipment Covered Services and Limitations Module PERCUSSORS Covered for mobilizing respiratory tract secretions Equipment Supplies HCPCS Code Range E0480 Suppl
88. pair of braces e Devices for the legs arms back and neck and trusses e Braces include rigid and semi rigid devices that are used for the purpose of supporting weak or deformed body members or for restriction or eliminating motion in a diseased or impaired part of the body e Back braces include but are not limited to corsets special sacroiliac sacrolumbar or dorso lumbar e Foot shoe inserts Indications Limitations e Except when documentation indicates excessive wear or necessary increase in size due to growth only one pair of orthopedic shoes is covered in a one year period e Coverage of orthopedic shoes is limited to one pair at the time of purchase e Cranial orthotics will be covered when initiated in patients who are 18 months or younger and the following criteria are met A As part of the post operative treatment plan following surgical correction of synostotic plagiocephaly i e craniosynostosis or B For the treatment of moderate to severe positional plagiocephaly when the following conditions are met 1 Documentation of failure of a 2 month trial of conservative therapy repositioning and or physical therapy and 2 Anthropometric data verifying moderate to severe plagiocephaly through a difference of asymmetry greater than 6 mm in one of the following measurements i Skull base ii Cranial vault iii Orbitotragical depth or 3 Cephalic index 2 standards deviations below mean head is narrow for its length or 2 standar
89. pairment of ANY ONE of the following e Vision e Cognition e Judgment Client must demonstrate through trial period with similar POV the following e Ability to safely and independently operate POV controls Medical Supplies and Equipment Covered Services and Limitations Module e Ability to transfer safely in and out of POV e Client has adequate strength and postural stability to safely ride in POV A POV is not appropriate due to any ONE of the following e Alternative to joy stick finger or thumb controlled tilter required e Modified frame required e Client requires complex supports or seating needs that can only be met via power wheelchair options e Client s prognosis indicates a potential for further decline in the short term i e there will be a requirement for additional support offered by a power wheelchair Documentation Y4 Written Order that specifies ALL of the following components and accessories Postural supports including ANY ONE of the following o None o Safety belts or straps Arm rests including ANY ONE of the following o None o Fixed o Swing up Battery including ANY ONE of the following o Gel Cell o Lead acid wet cell o Sealed lead acid Wheel drive including ANY ONE of the following o Front o Mid or center o Rear Tires including ANY ONE of the following o Pneumatic o Foam filled o Solid Control system including ANY ONE of the following o Standard filter with thumb controls o Tilter with
90. pment e Providing medical supplies in quantities of not more than one month s use Stockpiling is inappropriate e Obtaining prior authorization PRIOR to delivery of services on codes identified as requiring PA Medical Supplies and Equipment Covered Services and Limitations Module e Confirmation of continued need for disposable supplies by contact with clients or clients caretaker prior to shipment of supplies e Retaining documentation of current physicians orders in patient files e Informing clients in writing of their financial responsibility prior to providing services equipment which Wyoming Medicaid does not cover Coverage The Medical Supplies and Equipment List included in this manual contain specific information indicating what items are and are not covered by Wyoming Medicaid This is not an all inclusive list contact Xerox to determine if a specific code is covered Coverage is limited to the type or level of equipment that meets the needs of the client and is the most cost effective Wyoming Medicaid or its designee reserves the right to request documentation stating why a less expensive comparable alternative to requested equipment or supplies is not practical or stating alternate equipment or supplies are not available Reimbursement Guidelines Reimbursement for most medical supplies is established by fee schedules and reviewed annually to ensure appropriateness Payment is limited to the lower of the
91. ponent Per 15 Minutes K0740 will be used for Repair or Nonroutine Service for Oxygen Equipment Requiring the Skill of a Technician Labor Component Per 15 Minutes Suppliers should use K0739 on DME claims to bill for the labor associated with the reasonable and necessary repair of beneficiary owned durable medical equipment S5035 Home Infusion Therapy Routine Service Of Infusion Device E G Pump Maintenance Limitations This code does NOT cover the following e Repairs for rental equipment or equipment under warranty e Assembling delivering and setting up client equipment e Routine maintenance such as equipment inspection and battery change etc o Note Coverage is allowed for the labor related to battery changes that require the skills of a trained technician such as the battery changes for power wheelchair and Medical Supplies amp Equipment Covered Services and Limitations Module scooter batteries Documentation e For wheelchair repairs o No script or written order is required o The Certificate of Medical Necessity may be completed and signed by an ATP Assistive Technology Professional Prior authorization is required but the request may be submitted the same day the repairs were completed e For wheelchair evaluations no more than 2 hours will be allotted o Written order to complete a wheelchair evaluation e For all other repairs and for routine maintenance of an infusion pump o Written Order or Certificate of M
92. r Certificate of Medical Necessity or a letter of medical necessity or medical records that documents that the client meets the above criteria and includes the following clinical information e Results of blood gas study that has been ordered and evaluated by the attending physician specifically a measurement of partial pressure of oxygen PO2 in the arterial blood or e Measurement of oxygen saturation by pulse oximetry may also be acceptable when ordered and evaluated by the attending physician and performed under his her supervision or when performed by a qualified provider or supplier of laboratory services A pulse oximetry reading of the clients O2 saturation may be performed and documented by a provider and reviewed and signed off by the physician e Documentation must be updated on a yearly basis for continued rental Prior Authorization e Not Required for most oxygen and related equipment supplies e Prior Authorization is required for purchase of the following codes E0424 E0425 E0431 E0435 E0440 E1390 Milliman Care Guidelines Ambulatory Care 12th Edition Copyright 1996 1997 1999 2001 2002 2005 2006 2007 2008 Milliman Care Guidelines LLC All Rights Reserved Copyright strictly enforced Medical Supplies and Equipment Covered Services and Limitations Module PACEMAKER MONITORS SELF CONTAINED Covered for clients with cardiac pacemakers Equipment Supplies HCPCS Code Range E0610 E0620 Includes but is n
93. r chambers to one another frequency of air cycling for alternating pressure mattresses and air pressure that provides adequate client lift reduces pressure and prevents bottoming out e Surface designed to reduce friction shear and can be placed directly on a hospital bed frame e Automatically re adjusts inflation pressures with change in position of bed head or foot elevation e Purchased through capped rental only Air fluidized beds e Employ circulation of filtered air through silicone coated ceramic beads creating characteristics of fluid e May be purchased through capped rental only Indications Limitations Constant low pressure support mattress or mattress overlay is indicated for limited mobility or immobility and ANY ONE of the following e Presence or history of pressure ulcers e Acute illness e Advanced age e Impaired level of consciousness acute or chronic e Sensory or motor neurologic deficits e Chronic or terminal disease e Peripheral vascular disease e Malnutrition or dehydration e Fecal incontinence e Low tissue tolerance for pressure tissue paper skin Medical Supplies amp Equipment Covered Services and Limitations Module e Diabetes Documentation e Written Order or Certificate of Medical Necessity or a letter of medical necessity or medical records to document that the following conditions are met O O O Client is bedridden or chair bound Attending physician has performed comprehen
94. ral nutrition is not a legend drug and is included in the nursing facility per diem rate Documentation Written Order AND Current home assessment stating that environment in which nutrition therapy is to be given is safe and sanitary Documented systematic ongoing process which will increase client compliance and decrease negative outcomes Client profile consisting of the following Q O O O O O OUO Name age sex height and weight of client Current drug therapy including prescription and nonprescription drugs and home remedies Client s current diagnosis es in relation to therapy Client specific drug related problem list Goals for nutrition therapy Pertinent medical history Pertinent physical findings Pertinent laboratory findings Profiles must be updated on a quarterly basis to include Documentation of client education Additions to or deletions from nutrition therapy Outcomes associated with nutrition therapy Ongoing client assessments Results of ongoing laboratory tests Ongoing pertinent medical findings Information shall be made available upon request and maintained for six years after therapy is completed Medical Supplies and Equipment Covered Services and Limitations Module ENTERAL NUTRITION THERAPY Covered for clients who have a condition involving the GI tract somewhere between the mouth and the duodenum and require tube feedings to sustain life Equipment Supplies HCPCS Code Range B4034
95. re appropriate Repair and or replacement service must be available 24 hours per day A global fee has been established that includes Rental of the phototherapy unit and also all supplies accessories and services necessary for proper functioning and effective use of the therapy Complete caregiver training on use of equipment and completion of necessary records Reimbursement is limited to once per lifetime for a client Documentation Written Order AND Narrative report outlining client s progress Documentation of the above outlined criteria and conditions necessitating therapy must be maintained in provider s records Prior Authorization Not Required Medical Supplies amp Equipment Covered Services and Limitations Module PNEUMATIC COMPRESSORS and APPLIANCES Covered for clients with intractable edema of the extremities to administer pressure on the involved extremity with a pump set to deliver a prescribed amount of intermittent pressure Equipment Supplies HCPCS Code Range E0650 E0652 E0675 E0655 E0673 L4350 L4380 e Pneumatic compressors rental only e Upper and lower extremity pneumatic appliance for use with compressor purchase only Indications Limitations e Severe Swelling e Lack of drainage of lymphatic fluid e Severe circulation problems e Ulcers Documentation Written Order Prior Authorization Not Required References Medicare gov website Milliman Care Guidelines Ambulatory Care 12th Edit
96. ressure is greater than 25 mm Hg at rest or greater than 30 mm Hg with exercise AND 3 Client has significant symptoms from pulmonary hypertension such as severe dyspnea on exertion and either fatigability angina or syncope AND 4 Treatment with oral calcium channel blocking agents has been tried and failed or has been considered and ruled out Ultrasonic nebulizers are covered ONLY when other means of mobilization are documented by Medical Supplies and Equipment Covered Services and Limitations Module the physician to be ineffective Portable compressors with an internal battery feature REQUIRE specific documentation from the physician justifying the medical necessity of the portable feature All rental items must be billed with the RR modifier to indicate rental not purchase If KO730 is used to administer any other covered nebulizer drug other than Hoprost and the coverage criteria for not covered are met payment will be based on the allowance for the least costly medically appropriate alternative Documentation e Written Order or Certificate of Medical Necessity or letter of medical necessity or medical records to clearly document that client meets criteria above Prior Authorization Required References Wyoming Medicaid News dated November 2007 CMS 1500 Bulletin 7 14 http www fda gov Cder Drug InfoSheets patient iloprostPIS htm Medical Supplies amp Equipment Covered Services and Limitations Mo
97. ries Breast pump starter kit must be billed with TH modifier The TH modifier should only be billed for three months For billing Indicate the RR modifier for rental of breast pumps Medical Supplies amp Equipment Covered Services and Limitations Module Limitations Rental of breast pumps is limited to a maximum of three months per pregnancy unless additional months are medically necessary Criteria for Rental E0604 Breast pump heavy duty hospital grade is covered when documentation of medical necessity is supplied by the prescribing provider PRIOR AUTHORIZATION IS REQUIRED Pumps may be rented for up to three month time period under the following conditions k 2 3 4 Documentation Mother has diagnosis of breast abscess mastitis engorgement or other medical problem that necessitates short term rental of breast pump or Mother is hospitalized due to illness or surgery on a short term basis or Mother will receive short term treatment with medications that may be transmitted to the infant or Pediatric Healthcare provider determines need for short term rental of heavy duty pump due to serious medical condition of the infant Written Order or Breast Pump Certificate of Medical Necessity or a letter of medical necessity or medical records to substantiate that the criteria are met Billing under either mother s or infant s Medicaid ID number is acceptable however all documentation must match whichever ID number is be
98. roviders who provide services or items directly to clients It is not necessary for physicians offices to enroll as medical supply providers when providing supplies incidental to physician services Providers must e Enroll with Wyoming Medicaid as medical supply providers to bill for medical supplies and equipment included in this manual e Beenrolled with Medicare as medical supply provider as condition for enrollment with Wyoming Medicaid e Submit proof of DME accreditation e g CARF The Joint Commission as condition for enrollment with Wyoming Medicaid e Submit proof of re enrollment as a Medicare DMEPOS provider every three years following initial enrollment into the Wyoming Medicaid program Provider Responsibilities In supplying equipment and supplies providers are responsible for e Delivering correct ordered authorized equipment and or supplies and providing equipment serial numbers upon request from Wyoming Medicaid e Any modifications or additional equipment needed to correct provider error regarding client equipment and or supplies These costs are not billable to Wyoming Medicaid e Ensuring equipment provided be warranted by the manufacturer Provider s shall not bill Wyoming Medicaid or clients for equipment parts or services covered under warranty within the warranty period Copies of warranties must be submitted to KePRO or Wyoming Medicaid upon request e Providing maintenance repairs and parts for rental equi
99. rs but all documentation must be maintained in the provider s files References Milliman Care Guidelines Ambulatory Care 12th Edition Copyright 1996 1997 1999 2001 2002 2005 2006 2007 2008 Milliman Care Guidelines LLC All Rights Reserved Copyright strictly enforced Wyoming Medicaid News dated November 21 2003 Wyoming Medicaid News dated July 2005 Medical Bulletin 06 014 Medical Supplies and Equipment Covered Services and Limitations Module WHEELCHAIR SEATING SYSTEM Spinal Orthosis Seating System e Must be ordered by a physician pediatrician orthopedist neurosurgeon neurologist or a physiatrist a physician specializing in physician rehabilitation e It is expected that physicians be experienced in evaluating the child s special needs for the purpose of prescribing the correct customized features e Covered when required to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured body part e A seating system for use with a wheelchair is covered when medically necessary for use with a medically necessary wheelchair base for a client who has a diagnosed medical condition that impairs their ability to sit e Supporting the client in a position that minimizes the development or progression of musculoskeletal impairment A wheelchair seating system may be covered for the purpose of e Relieving pressure or e Providing support in a position that improves the client
100. s Equipment Supplies HCPCS Code Range E0130 E0149 Any type of walker Indications Limitations Heavy duty walker covered for client s whose weight within one month of providing the walker is greater than 300 pounds Heavy duty multiple braking system variable wheel resistance walker covered for clients who meet coverage criteria for a standard walker and are unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand Note Obesity by itself is not a sufficient reason for heavy duty multiple braking system variable wheel resistance walker If heavy duty walker is provided and the coverage criteria for a standard walker are met but the additional coverage criteria for a heavy duty multiple braking system variable wheel resistance walker are not met payment will be based on the allowance for the least costly medically appropriate alternative depending on the client s weight Medical necessity of a walker with an enclosed frame when compared to a standard folding wheeled walker has not been established Therefore if the basic coverage criteria for a walker are met and a walker with an enclosed frame is billed payment will be based on the allowance for the least costly medically appropriate alternative Walker with trunk support is considered a gait trainer please refer to the gait trainer policy Enhancement accessories for walkers are non covered bec
101. s Module NOTE Seat lift mechanisms that operate by spring release action with a sudden catapult like motion that jolts the individual from a seated position to a standing position are not covered For other patient lifts Client caregiver must be able to use lift and has completed successful trial if first time Without the use of a lift client would be confined to bed or Transfer between bed and a chair wheelchair or commode requires the assistance of more than one person Supplies accessories are covered as replacement for client owned patient lift only and CANNOT be billed in addition to rental equipment slings or seats canvas or nylon Documentation Written Order or Certificate of Medical Necessity or letter of medical necessity or medical records to document that client meets established criteria above Prior Authorization Required References Milliman Care Guidelines Ambulatory Care 12th Edition Copyright 1996 1997 1999 2001 2002 2005 2006 2007 2008 Milliman Care Guidelines LLC All Rights Reserved Copyright strictly enforced MILLIMAN and CARE GUIDELINES are registered trademarks of Milliman Inc Last Update 2 11 2008 12 26 14 PM Medical Supplies and Equipment Covered Services and Limitations Module Medical Foods Benefits Limitations and Authorization Requirements Medical foods are a benefit of the Wyoming Medicaid program for clients under age 21 with inborn errors of metabolism that prohibit them from
102. s Module Power seat elevation system Mounting hardware is covered when it is needed in conjunction with other covered accessories Indications Limitations Manual wheelchair covered for clients who Have a diagnosed medical condition which impairs the ability to walk where long term risk of injury is high or the energy cost of standing mobility is great AND The client requires a wheelchair for the purpose of O Increasing independence with mobility resulting in significant difference in ability to perform major life activities or Providing assisted mobility for clients who show no means of safe independent mobility Preventing falls Preserving energy and strength Client should be evaluated for the most appropriate frame seating system including postural supports and cushions arm and leg rests propulsion method and tires or castors The goals of wheelchair seating are to maintain proper alignment accommodate skeletal deformity improve tone management decrease the likelihood of skin breakdown improve sitting tolerance and reduce pain Tilt in space and reclining back wheelchairs are appropriate for those who need significant assistance in positioning Power Wheelchair covered instead of a manual wheelchair if the client meets the criteria for a manual wheelchair but is unable to operate wheelchair manually due to ANY ONE of the following Absence or deformity of an extremity Inadequate upper extremity strength ra
103. s or wedges and there must be documentation as to why they did not work or e Client requires traction equipment which can only be attached to a hospital bed Variable covered if client meets one of the criteria for a fixed height hospital bed and requires a bed height different than a fixed height hospital bed to permit transfers to chair wheelchair or standing position Semi Electric_ covered if client meets one of the criteria for a fixed height bed and requires frequent changes in body position and or has an immediate need for a change in body position Heavy Duty covered if client meets one of the criteria for a fixed height hospital bed and the Medical Supplies and Equipment Covered Services and Limitations Module client s weight is more than 350 pounds but does not exceed 600 pounds Extra Heavy Duty covered if the client meets one of the criteria for a hospital bed and the client s weight exceeds 600 pounds Pressure reducing mattress covered for clients with or who are highly susceptible to pressure ulcers and whose physician will be supervising its use in connection with client s course of treatment Trapeze equipment covered if client needs this device to sit up because of a respiratory condition to change body position for other medical reasons or to get in or out of bed Heavy duty trapeze equipment covered if client meets the criteria for regular trapeze equipment and client s weight is more tha
104. s per hour with documented symptoms of excessive daytime sleepiness impaired cognition mood disorder or insomnia or documented hypertension ischemic heart disease or history of stroke Medical Supplies amp Equipment Covered Services and Limitations Module o Any other relevant copies of client s sleep lab evaluations pulmonary function tests sleep latency testing and 02 saturations o Present physical symptoms Morning headache fatigue level increase in irritability difficulty with memory or intellect o Pertinent lab values e g elevated PaC02 etc Other methods attempted and why they were deemed inappropriate or ineffective o Follow up at 1 3 months intervals documenting improvement in the client s condition O Prior Authorization Required References Milliman Care Guidelines Ambulatory Care 12th Edition Copyright 1996 1997 1999 2001 2002 2005 2006 2007 2008 Milliman Care Guidelines LLC All Rights Reserved Copyright strictly enforced MILLIMAN and CARE GUIDELINES are registered trademarks of Milliman Inc Last Update 2 11 2008 12 26 14 PM Wyoming Medicaid News dated November 2007 CMS 1500 Bulletin 07 012 Medical Supplies and Equipment Covered Services and Limitations Module DELIVERY of DME OUTSIDE PROVIDER NORMAL SERVICE AREA Mileage Covered for equipment purchases and also in conjunction with repairs on purchased equipment Indications Limitations Does not cover delivery of dispo
105. s severely impaired or e Required for use in connection with durable medical equipment for purposes of moisturizing oxygen or e Treat respiratory conditions including chronic bronchitis emphysema cystic fibrosis HIV organ transplant complications tracheostomy or other illnesses that cause thick mucus secretions Ultrasonic nebulizers are covered only when other means of mobilization are documented by the physician to be ineffective Heated nebulizers are covered for clients with tracheotomies that require heated oxygen Portable compressors with an internal battery feature requires specific documentation from the physician justifying the medical necessity of the portable feature The following supplies accessories are covered as replacement for use with client owned equipment for a client whose condition meets the criteria for coverage of the compressor and CANNOT be billed with rental equipment e Mouth pieces e Face tents e Filters e Tubing Distilled water is not covered for billing of medications for inhalation therapy see the Pharmacy Services Billing Module Documentation Written Order Prior Authorization Not Required References Centers for Medicare amp Medicaid Services Medical Supplies amp Equipment Covered Services and Limitations Module NEUROMUSCULAR ELECTRICAL STIMULATORS NMES Intact including brain spinal cord and peripheral nerves and other non neurological reasons for disuse are causing
106. sable supplies Delivery destination must be outside the DME Provider s normal service area Delivery of items must be more cost effective than shipping unless fitting is necessary or assembly is required In some instances it is acceptable to have someone family team guardian etc other than the provider assemble the equipment Reimbursement is paid according to the total distance from the city of the provider s place of business to the DME destination city the first 50 miles are not reimbursable Providers may only bill for one trip regardless of the number of items being delivered to the same destination or general area and should therefore make every effort to coordinate delivery of items e g if a provider from Cheyenne had to deliver equipment to the following areas Casper Riverton and Lander the provider should bill the mileage on the claim for the client in Lander or Riverton whichever is the furthest distance away Documentation Claims for travel miles must be included with a claim for the equipment that was delivered and the DME Mileage Verification Form must be attached to the claim To obtain mileage form visit http wyequalitycare acs inc com forms DME_Mileage Verification _6 20 12 pdf Reimbursement will be at the state rate of 0 40 per mile Use code A9901 1 unit equals 1 mile for any miles over 25 each way e g A provider traveling 52 miles roundtrip to deliver and fit a wheelchair would bill 2 units using code
107. sitioned while seated or while in bed Client s turning and repositioning schedule as pertains to individual Explanation of client s incontinence and how it is being appropriately managed Documentation of debridement of necrotic tissue AND documentation of how much necrosis CURRENTLY in wound bed Description of any current infection systemic and or wound site AND current treatment For diabetic ulcers documentation that client has been on a comprehensive diabetic management program as evidenced by Fingerstick other blood glucose results Current hemoglobin A1C Current diabetic medication regimen For Venous insufficiency ulcers evidence that the following interventions have been utilized Medical Supplies and Equipment Covered Services and Limitations Module e Compression stockings and or bandages have been consistently applied e Leg elevation above the level of the heart e Avoidance of extended periods of time in one position sitting or standing e Ambulation has been encouraged as appropriate Written documentation that client does not fall into any contraindicated categories listed under limitations below and why vacuum assisted closure is appropriate if client does have any of the following precautionary therapy symptoms e Clients receiving anticoagulant therapy e Clients experiencing difficult hemostasis following debridement Prior Authorization Required References Milliman Care Guidelines Ambulatory Care 12th Ed
108. sive assessment documenting Stage MI or IV decubitus ulcer s or post operative healing of major skin grafts or myocutaneous flaps on trunk and pelvis Client should be placed on bed unit immediately after surgical procedure to promote healing and protect skin integrity Description of all alternative equipment and conservative treatment methods that have been attempted and why attempts were deemed inappropriate or ineffective Trained adult caregiver is available to assist client with activities of daily living and management and support of the air fluidized bed system Evidence that absence of bed would leave client needing be to institutionalized Prior Authorization Required References CPT copyright 2007 American Medical Association All rights reserved Milliman Care Guidelines Ambulatory Care 12th Edition Copyright 1996 1997 1999 2001 2002 2005 2006 2007 2008 Milliman Care Guidelines LLC All Rights Reserved Copyright strictly enforced Medical Supplies and Equipment Covered Services and Limitations Module APNEA MONITOR Apnea monitors are exempt from capped rental and covered on a rental basis for clients that meet one of the following e One or more apparent life threatening events requiring mouth to mouth resuscitation or vigorous stimulation e Episode characterized by some combination of apnea or color change choking or gagging e Symptomatic pre term infants e Sibling of SIDS victim e Medical condition such
109. t Covered Services and Limitations Module MEDICAL SUPPLIES AND EQUIPMENT LIST COVERAGE POLICIES The following pages outline specific coverage policy for supplies and services for specific codes please refer to the Healthcare Common Procedure Coding System HCPCS or on the Xerox Wyoming Medicaid website http wyequalitycare acs inc com for online fee schedules This list contains the medical supplies and equipment covered by Wyoming Medicaid subject to the conditions stated herein and subject to changes adopted by federal or state law changes in policy or procedures or changes announced in Wyoming Medicaid Information Bulletins or via Remittance Advice banners The Supplies and Equipment List includes the following e Criteria for approval e Information regarding whether Prior Authorization is required e Limits on quantity Please remember that all rental items are subject to capped rental unless otherwise specified Claims that are submitted with rental items should contain the appropriate code followed by the RR modifier To verify whether a particular item requires Prior Authorization contact Xerox or refer to the Xerox W yoming Medicaid website e http wyequalitycare acs inc com e Click on fee schedule then review accept terms of use e Click on Try our procedure code search here e Enter the code and search Providers may contact Xerox in writing with a request to cover any code not covered This reques
110. t must include a complete description of the item including brand product number size etc Use procedure code modifiers when appropriate A physician s written order is required Wyoming Medicaid may request additional documentation Prior authorization is required MEDICAL SUPPLIES AND EQUIPMENT LIST PA Requirement AIR FLUIDIZED AND LOW AIR LOSS BED UNITS See Also BEDS and ACCESSORIES APNEA MONITOR BATH and TOILET AIDS BEDPANS and URINALS BEDS AND ACCESSORIES includes TRAPEZE Yes BLOOD GLUCOSE MONITORING Required only for continuous glucose monitoring systems BLOOD PRESSURE MONITORS No BREAST PROSTHESES No BREAST PUMPS e Standard manual grade breast pump e No e Heavy duty hospital grade electric breast pump Yes Medical Supplies and Equipment Covered Services and Limitations Module MEDICAL SUPPLIES AND EQUIPMENT LIST PA Requirement CANES AND CRUTCHES No COMMODES Required for E0170 CONTINUOUS PASSIVE MOTION CPM DEVICES Yes C PAP BI PAP MACHINE Yes No DELIVERY of DME OUTSIDE PROVIDER NORMAL SERVICE AREA Mileage DIALYSIS EQUIPMENT and SUPPLIES DRESSINGS Not covered as DME see policy EYE PROSTHESES GAIT TRAINERS HEAT COLD APPLICATION DEVICES INCONTINENCE APPLIANCES and CARE SUPPLIES INFUSION PUMPS EXTERNAL and ACCESSORIES maintenance of infusion pumps Y INHALATION CONTROLLED DOSE DRUG DELIVERY Y INHALATION SYSTEM INT
111. tburn and reflux e Nocturia or nocturnal enuresis e Night sweats e Mood disorder e Impaired cognition e Fibromyalgia like symptoms 4 Documented cardiovascular disease e g hypertension ischemic heart disease heart failure stroke 5 Severe obstructive sleep apnea 6 Upper airway resistance syndrome UARS associated with unexplained excessive daytime sleepiness 7 restrictive lung disease or hypoventilation syndromes associated with hypercapnia 8 Reasons where CPAP may not be an option include e No well supported home CPAP titration services available B e Patient does not have ability to manage equipment e Heart failure e Chronic obstructive pulmonary disease COPD or other lung disease e Obesity hypoventilation syndrome Child Qualification Criteria Includes 1 Signs and symptoms consistent with obstructive sleep apnea 2 Nocturnal signs and symptoms such as e Pauses in breathing e Gasps e Signs of increased respiratory effort i e nasal flaring e Enuresis e Sweating e Snoring 3 Daytime signs and symptoms such as e Nonspecific behavioral problems Documentation e Written Order or Certificate of Medical Necessity or letter of medical necessity to describe specific indications for the client e Documentation must also be maintained in the file to include the following if applicable to condition symptoms o AHI greater than or equal to 15 events per hour or o AHI greater than or equal to 5 and less than or equal to 14 event
112. term rental chair for a period not to exceed 120 days Replacement due to malicious damage culpable neglect or wrongful disposition will not be covered When a wheelchair is no longer suitable because of growth development or changes to the client s condition and must be replaced the client the provider and Wyoming Medicaid may negotiate a good faith trade in of the item no longer needed Such a trade in shall be used to reduce the reimbursement from Wyoming Medicaid on the new item No more than 2 hours will be allotted for wheelchair evaluations The evaluation must include evaluator s credentials and signature and measurements of o Height amp Weight Seat Width and Depth Hip to Knee Knee to Foot Back Height Please refer to the policy on Repairs Labor Maintenance for further information on documentation and prior authorization requirements for evaluations O 0O 0O 0 Medical Supplies and Equipment Covered Services and Limitations Module Equipment Supplies HCPCS Code Range E0950 E1298 E2201 E2399 E2601 E2621 Must be medically necessary and may include but is not limited to e Manual wheelchairs e Light weight and heavy duty wheelchairs e Powered wheelchairs Including ANY ONE of the following e Standard sling back and seat Specialty seating including ANY ONE of the following e Custom molded refer to policy on Seating Systems e Solid e Gel e Air flotation e Foam Frame modifications including ANY ONE o
113. the information is received within thirty 30 days of the denial with a clearly articulated request for reconsideration it will be handled as such If the information is received more than thirty days after the denial it will be considered to be a new Prior Authorization request As such a new Prior Authorization form must be submitted and all information to be considered must accompany it In the case of a denial that is based on the client not meeting criteria two options exist either additional information can be sent or a peer to peer conversation can be requested between the ordering Physician and the Physician who reviewed the PA request Either option must be exercised within thirty 30 days of the date on the denial letter Contact KePRO to arrange for a reconsideration Medical Supplies and Equipment for Nursing Facilities Wyoming Medicaid pays a per diem rate to provide room dietary services routine services medical supplies equipment etc for nursing facilities In general routine medical supplies and equipment covered in the per diem rate for clients residing in nursing facilities are not reimbursed separately but specialized equipment can be covered in addition to the per diem rate Refer to the Definition section of this manual for information about specialized equipment versus routine equipment To review the DME items that are included in the nursing facility per diem rate you can access the Nursing Facil
114. the previous two month period of use o Estimated additional length of time monitor would be needed o Any additional pertinent information the physician may wish to provide Prior Authorization Not Required Medical Supplies amp Equipment Covered Services and Limitations Module BATH and TOILET AIDS Covered for purchase for clients with medical conditions which cause decreased stability and safety with ambulation Bathtub patient lifts and rehabilitation shower chairs are covered for clients with medical conditions who without use of the equipment would be unable to bathe or shower Equipment Supplies HCPCS Code Range E0240 E0249 E0167 E0175 Covered items include but are not limited to bath toilet rails raised toilet seats tub stools and benches transfer tub benches and attachments and bath support chairs Indications Limitations Hand held shower attachments faucet adapters etc are not covered Documentation Written Order Prior Authorization Not Required Medical Supplies and Equipment Covered Services and Limitations Module BEDPANS and URINALS Covered for clients who are confined to bed Equipment Supplies HCPCS Code Range E0275 E0276 E0325 E0326 Includes but is not limited to bed pans and urinals Indications Limitations N A Documentation Written Order Prior Authorization Not Required Medical Supplies amp Equipment Covered Services and Limitations Module BEDS AND ACCESSORIES Covered for
115. tion or disability Gii The expected use is in accordance with current medical standards or practices iv Is cost effective v Provides for a safe environment or situation for the client vi For the purposes stated utilization is not experimental not investigational and is generally accepted by the medical community and vii Its primary purpose may not be to enhance the personal comfort of the recipient nor to provide convenience for the recipient or the recipient s caregiver Misuse Intentional utilization of equipment in a manner not prescribed or recommended which results in the need for repairs or replacement or allowing use by persons other than the client for whom the item was specifically prescribed Neglect Failure to maintain the equipment as specified by the provider Orthotics Rigid or semi rigid devices to prevent or correct physical deformity or malfunction Over the Counter All drugs and supplies which by law do not require a prescription to be dispensed or sold to the public Prosthetics Replacement corrective or supportive devices prescribed by a physician to e Artificially replace a missing portion of the body e Prevent or correct physical deformity or malfunction e Support a weak or deformed portion of the body Reasonable In accordance with current accepted standards of medical practice in the treatment of the client s condition without excess or extreme function or expense beyond that
116. umber E 76 Topic Walkers Issue Date 12 3 1 07 Effective Date 1 1 08 Medical Supplies amp Equipment Covered Services and Limitations Module WHEELCHAIRS Manual amp Power Wheelchairs are available for purchase or rental wheelchairs are intended for home use and must be accessible in the home All wheelchairs must carry the manufacturer s warranty as part of the purchase price Serial numbers must be provided upon request from Wyoming Medicaid for new equipment Assembly and delivery is included in purchase price Repairs Wyoming Medicaid covers repairs to a wheelchair owned by a client with appropriate documentation and a determination of cost effectiveness Replacements Wheelchairs may only be replaced on a five year basis unless there are extenuating circumstances such as e Client has grown more than expected e A change in the client s physical condition e Extensive wear of the wheelchair If a wheelchair is lost or stolen the medical provider requesting a new wheelchair must obtain a copy of the police report The medical provider must either document on the prior authorization request that a copy has been obtained or send a copy with the request Wyoming Medicaid will not consider authorization until two months after the filing of the police report to ensure adequate time for possible recovery of the wheelchair If the chair is necessary for the client to maintain independence Wyoming Medicaid will consider a short
117. und or has limited mobility but cannot independently make changes in body position significant enough to alleviate pressure or Is completely immobile and cannot make changes in body position without assistance e The client must have a care plan established by the physician or other licensed healthcare practitioner directly involved in the client s care which should include the following O O O 0 0 70 Adherence Education of the client and caregiver on the prevention and or management of pressure ulcers Regular assessment by a licensed healthcare practitioner Appropriate turning and positioning Appropriate wound care for Stage II IH or IV ulcer Moisture incontinence control if needed and Nutritional assessment and intervention consistent with the overall plan of care if there is impaired nutritional status to the care plan treatment is not to be construed as elements for coverage criteria Prior Authorization Items in this category may require PA Please refer to online fee schedule located on the Xerox Wyoming Medicaid website or contact Xerox Provider Relations to determine if PA is required Medical Supplies and Equipment Covered Services and Limitations Module PROSTHETICS Coverage for prosthetics Equipment Supplies HCPCS Code Range L5000 L9999 Terminal device s e Hook e Hand Lower limb device s FEET Basic lower extremity prostheses include a SACH foot Based on client functional classific
118. which is necessary Specialized For purposes of distinguishing whether equipment is specialized or routine in order to determine whether Wyoming Medicaid covers the equipment outside of the nursing home per diem rate the following criteria applies e Is the equipment generally needed by nursing home residents If so then it is not specialized i e beds mattresses commodes wheelchairs walkers e Is the equipment customized or custom fitted i e orthotics prosthetics hearing aids custom seating or wheelchair accessories power wheelchair accessories If so then it is specialized Medical Supplies and Equipment Covered Services and Limitations Module e Is the equipment intended solely for the use of a specific resident and will never be nor could it be useful to another resident If so then it is specialized Standard versus Deluxe A standard item is cost effective for the condition compared to alternative interventions including no intervention Cost effective does not necessarily mean the lowest price but is the most appropriate supply or level of services required to provide safe efficient and adequate care A deluxe or Luxury item offers no additional medical advantage to the client although it is more costly extravagant nicer in appearance etc If more than one piece of DME can meet the client s needs coverage is only available for the most cost effective piece of equipment Medical Supplies amp Equipmen
119. wounds o Flaps grafts amp burns on a case by case basis of greater than 1mm in depth and Medical records that document o Wound is not infected No active bleeding No eschar Minimal or no necrotic tissue Area of decubitus must be in an area which is difficult to heal e g sacral or ischial area and Certificate of Medical Necessity or letter of medical necessity or medical records that document o That the client does not fall into any of the Precaution or Contraindication categories listed and o Description of conservative treatments and alternative measures or equipment attempted and why they were deemed inappropriate or ineffective and Information regarding who will maintain the equipment and provide ongoing communication as to the effectiveness of the V A C and 0O 0O 0 O For continuation beyond one month of therapy documentation must reflect the following After four weeks of therapy a minimum of a twenty percent decrease in size and volume of decubitus ulcer After eight weeks of therapy a minimum of a sixty percent decrease in size and volume of decubitus ulcer After twelve weeks of therapy a minimum of a ninety percent decrease in size and volume of decubitus ulcer Circumstances that lead to wound development Current wound labs as well as current nutritional status including any prescribed supplements Evidence as pertains to individual client that client has been appropriately encouraged and or turned and repo
120. y management is recommended to all patients with PKU These recommendations are based on a growing body of evidence indicating there is a decline in average IQ and development of difficulties in school performance after diet discontinuation We appreciate your attention to this request for patient s name s medical formula name of medical formula to be covered by his her current medical insurance Please to not hesitate to contact us if you have any questions at clinic contact info Sincerely dietician name RD LDN Physician name M D cc parents name physician credentials clinic name Medical Supplies and Equipment Covered Services and Limitations Module MEDICAL SURGICAL SUPPLIES Covered for clients who require home treatment of a specific medical condition protection or support of a wound surgical incision or diseased or injured body part Equipment Supplies HCPCS Code Range A4206 A6404 Includes but is not limited to e Syringes e Needles e Irrigation trays e Tape e Disposable underpads e Lubricant Indications Limitations None Documentation Written Order Prior Authorization Not Required Medical Supplies amp Equipment Covered Services and Limitations Module MEDICATION DISPENSER Automatic Covered for clients who are unable to effectively and safely self medicate due to a medical or mental condition or are non compliant due to lack of supervision Item is subject to capped rental

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