Durable Medical Equipment, Medical Supplies, Prostheses and Orthoses
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Payment Policy: Durable Medical Equipment, Medical Supplies, Prostheses and Orthoses Reference Number: FL.CLMS.05 (Medicaid) Product Types: MMA Effective Date: 03/10/2021 Last Review Date: 03/09/2021 Coverage and Billing Guide Sunshine Health provides coverage for medically-necessary Durable Medical Equipment (DME) and medical supplies pursuant to the Statewide Medicaid Managed Care (SMMC) program. Medical equipment is used to manage and treat a condition, illness, or injury. DME is used over and over again, and includes things like wheelchairs, braces, crutches and other items. Medical supplies are used to treat and manage conditions, illnesses or injury. Medical supplies include things that are used and then thrown away, like bandages, gloves and other items. Additional items, including personal toiletries and household items such as detergent, bleach and paper towels may be covered as medically necessary for Long Term Care/Comprehensive members. General Authorization DME and medical supplies may require authorization for Medicaid members prior to delivery. To verify authorization at the code level, please use Sunshine Health’s on-line prior authorization validation process at sunshinehealth.com/providers/preauth-check/medicaid-pre-auth.html All DME and medical supplies require authorization for Long Term Care/Comprehensive members. Codes Not Listed/Priced on Medicaid Fee Schedule Covered procedure codes not listed on the Medicaid Fee Schedule, not priced on the Medicaid Fee Schedule or not specifically referenced in the provider agreement are reimbursable. HCPCS: E0602, E0784, K0606, L7007, L7009 are reimbursed off the Medicare Fee Schedule. All other unlisted or unpriced codes are priced at 105% of the invoice or based on a negotiated Single Case Agreement (SCA). Bundle Codes Bundled codes are only for rentals. Bundle services are considered global to the applicable Medicaid Fee Schedule rental rate. If the service is being provided to owned equipment, the services are payable as stand-alone services. MMA_2775 Modifiers Certain procedure codes have modifiers that are used with the HCPCS procedure codes to more fully describe the procedure performed. Please see procedure code modifiers for additional information. Rent-to-Purchase For rent-to-purchase equipment, Medicaid’s total reimbursement may not exceed a total of ten (10) monthly claims. The provider may not submit a claim for more than one unit of service within the same calendar month. When the tenth and final payment is made for a specific rent-to- purchase item, the equipment becomes the personal property of the Medicaid recipient. Rental-only items remain the property of the provider, regardless of the number of months the item is rented. Reimbursement fees for rental-only items include all necessary home visits, repair and maintenance. Rental only equipment may be purchased if medically necessary. A request must be submitted via prior authorization and an SCA obtained. Customized Equipment/Brand Supplies Requests for customized equipment or specific brand supplies, such as wheelchairs may be approved based on Medical Necessity. A request must be submitted via prior authorization and an SCA obtained. Excess Limits and Coding Requests for variances to coding and service limits may be approved based on Medical Necessity. This includes items that may be billed under a miscellaneous codes. Miscellaneous codes should only be used when a more appropriate code does not exist. (For example the DME miscellaneous code E1399 is utilized for Robotic Arm.) A request must be submitted via prior authorization and an SCA obtained. Supplies/Maintenance/Repairs Unless otherwise stated, services also include supplies, repair, maintenance and replacement of all covered, medically-necessary rented or owned equipment that is not covered under the warranty period. This includes equipment that may have been purchased prior to enrollment with Sunshine Health. Certain equipment might be eligible for replacement if purchased prior to enrollment EG oxygen equipment. Additional Payment or Clinical Policies Mechanical Stretch Devices sunshinehealth.com/content/dam/centene/policies/clinical-policies/CP.MP.144.pdf Wheelchairs and Accessories sunshinehealth.com/content/dam/centene/policies/payment-policies/CC.PP.502.pdf sunshinehealth.com/content/dam/centene/policies/clinical-policies/CP.MP.99.pdf Covered Services and Codes Ambulatory Aids An ambulatory aid is a medically-necessary item that is required by a recipient with impaired ambulation. Ambulatory aids include canes, crutches, and walkers that are to be complete with tips, pads, and grips. Pediatric gait trainers may be reimbursed as an ambulating aid. Wheeled walkers with a seat and wheel locks may be reimbursed, when prescribed in lieu of a wheelchair. Apnea Monitors An apnea monitor is a device to detect the cessation of breathing in infants and adults who are at risk of respiratory failure and alert the parent or attendant to the condition. Augmentative and Alternative Communication Systems AAC devices are designed to allow individuals to communicate. As defined by the American Speech- Language Hearing Association (ASHA), an AAC device attempts to compensate for the impairment and disability patterns of individuals with severe, expressive communication disorders, i.e., individuals with severe speech-language and writing impairments. Dedicated AAC systems are designed specifically for a disabled population. Non-dedicated systems are commercially available devices such as laptop computers with special software and are not reimbursable by Medicaid. Bathroom and Toileting Aids Bathroom and toileting aids are devices available to assist recipients who are incapable of using standard toilet facilities. Bedpans and urinals may be reimbursed when a recipient is confined to a bed. A portable commode may be reimbursed if a recipient has limited or no access to toilet facilities. A detachable or drop arm commode may be reimbursed if a recipient cannot perform a pivot transfer without assistance. Compressors Compressors are machines that compress air into storage tanks for use by air driven equipment. Medicaid may reimburse for an air power source compressor when it is used to support medically- necessary DME that is not self-contained, or with a nebulizer that provides at least 50 pounds per square inch (psi). Custom Cranial Remolding Orthosis A custom cranial remolding orthosis is a non-invasive device used to correct the symmetry of an infant's skull. Disposable Incontinence Briefs, Diapers, Protective Underwear, Pull-Ons, Liners, Shields, Guards, Pads, Undergarments The disposable incontinence supplies as specified in the section are reimbursable only for use by individuals with chronic incontinence caused by a permanent physical or mental condition, including cerebral palsy and developmental delay. Glucose Monitors, Diabetic Testing Strips, Insulin Syringes and Blood Lancets Home glucose monitors, blood glucose, and urine keytone testing strips are covered for recipients whose documented medical condition requires frequent monitoring of urine or blood glucose levels. Insulin syringes are covered for recipients whose documented medical condition requires insulin to be injected. Blood lancets are used to pierce the skin for the purpose of obtaining a blood sample when monitoring blood glucose levels. Blood lancets are covered for recipients whose documented medical condition requires frequent monitoring of blood glucose levels. Heat Lamps and Pads Heat lamps and heating pads are appliances or equipment used to apply heat to areas of the body. Medicaid covers heat lamps and heating pads when prescribed by a treating physician to treat a condition or illness that requires the application of localized heat therapy to affected area(s) of the body. Hospital Beds, Mattresses, and Rails A standard hospital bed consists of a modified latch spring assembly mattress, bed ends with casters, and two manually operated foot end cranks. It is equipped with IV sockets and is capable of accommodating a trapeze bar, side rails, an overhead frame, and other accessories. Medicaid may reimburse for a semi-electric bed or an electric bed when it is medically necessary for a recipient who is cognitively and physically capable of safely adjusting the position of the bed by independently operating the bed controls. Medicaid may reimburse for a heavy-duty bed for recipients weighing in excess of 350 pounds. Medicaid may reimburse for trapeze equipment when a recipient is confined and needs help to get in or out of bed, change his body position, or sit up for a respiratory condition. Intermittent Catheter with Insertion Supplies Lymphedema Pump A non-segmental lymphedema pump is a device that has a single outflow port on the compressor that produces a set level of pressure. A segmental lymphedema pump is a device that has multiple outflow ports on the compressor that lead to distinct segments on the appliance that inflates sequentially. Medical Supplies To be reimbursed by Medicaid, in addition to the above criteria, medical supplies must be needed for use with one of the following: colostomy, urostomy, ileostomy appliances; or surgical, wound, and burn dressings; or Gastric feeding sets and supplies; or urinary catheters, irrigation apparatus, and related items; or tracheostomy and endotracheal care supplies; or disposable items, which if not provided could reasonably cause the recipient to require emergency treatment, become hospitalized, or be placed in a long