Chapter 14 Durable Medical Equipment (DME)

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Durable Medical Equipment (DME)Other InformationAdded: Priorauthorizationsfor rental…ofthe ACDdevice.TopicInvoiceTrial PeriodRepairLoss/DamageComponent /Accessory LimitsWheelchairsRequired for the PAThe prior authorization request and the manufacturer’s invoice mustbe forwarded to EDS Prior Authorization department.No communication components will be approved unless the clienthas used the equipment and demonstrated an ability to use theequipment.Prior authorization for rental may be obtained for a trial period. Thisdemonstrated ability can be documented through periodic use ofsample/demonstration equipment. Adequate supportingdocumentation must accompany the request.Prior authorizations for rental of ACD device E2510 may be approvedfor a four (4) week trial period of usage by the recipient. Themanufacturer must agree to this trial period. Medicaid will reimbursethe manufacturer for the dollar amount authorized by the Agency forthe four (4) week trial period. This amount will be deducted from thetotal purchase price of the ACD device.Repairs are covered only to the extent not covered by manufacturers’warranty. Repairs must be prior approved. Battery replacement is notconsidered repair and does not require prior authorization.Replacement of identical components due to loss or damage must beprior approved. These requests will be considered only if the loss ordamage is not the result of misuse, neglect, or malicious acts by theusers.No components or accessories will be approved that are notmedically required. Examples of non-covered items include but arenot limited to the following:• Printers• Modems• Service contracts• Office/business software• Software intended for academic purposes• Workstations• Any accessory that is not medically required.To qualify for Medicaid reimbursement of a wheelchair, the physician must prescribethe equipment as medically necessary for the recipient. Request for coverage must bereceived by EDS within thirty calendar days after the date that the equipment wasdispensed. The recipient must be essentially bed confined and must meet the followingdocumented conditions:Deleted: to Section 14.5.3Added: Appendix PDeleted: Effective October1, 2000, beganreimbursingAdded: reimbursesDeleted: Medicare’sprocedure codeAdded: HCPC code• The recipient must be essentially chair confined or bed/chair confined.• The wheelchair is expected to increase mobility and independence.A standard wheelchair (procedure code E1130) should be requested unlessdocumentation supports the need for any variation from the standard wheelchair. Anexample of this variation is an obese recipient who requires the wide heavy-dutywheelchair (E1093). For a list of valid wheelchair procedure codes, refer Appendix P,Procedure Codes and Modifiers.Medicaid reimburses Durable Medical Equipment providers for Extra Heavy DutyWheelchairs. These wheelchairs accommodate weight capacities up to 600 lbs.Medicaid covers these wheelchairs as a purchase by using HCPC code K0007.14-18 April 2005
Durable Medical Equipment (DME) 14Medicaid covers the other manual wheelchair base to accommodate weightcapacity of 600 pounds or greater. The other manual wheelchair base will becovered using HCPC code K0009. The wheelchair component or accessory nototherwise specified for the wheelchair will be covered using procedure code K0108(an already existing code). We will use the established prior authorization criteriafor the other manual wheelchair base, and the wheelchair component or accessorynot otherwise specified. Medicaid will require provider to submit available MSRPSfrom three manufacturers for the items. Medicaid will require weight, width anddepth specification for these items.NOTE:The provider must ensure that the wheelchair is adequate to meet the recipient’sneed. For instance, providers should obtain measurements of obese recipients toascertain body width for issuance of a properly fitted wheelchair.This equipment may be purchased for any qualified Medicaid recipient who meets theabove criteria. This equipment may also be rented for any recipient under the age of 21who is referred under the EPSDT program. The information submitted must includedocumentation that the recipient meets the above medical criteria.MOTORIZED/POWER WHEELCHAIRSThe Alabama Medicaid Agency covers motorized/power wheelchairs and to qualifyfor the motorized/power wheelchairs an individual must meet full Medicaid financialeligibility and established medical criteria. All requests for motorized/powerwheelchairs are subject to Medicaid Prior Approval provisions established by theAlabama Medicaid Agency. The patient must meet criteria applicable to manualwheelchairs pursuant to the Alabama Medicaid Agency Administrative Code Rule No.560-X-13-.17. The attending physician must provide documentation that a manualwheelchair cannot meet the individual’s medical needs, and the patient must requirethe motorized/power wheelchair for six (6) months or longer.The following are policies related to the coverage of motorized/powerwheelchairs:• Motorized/power wheelchair base codes covered are K0010, K0011, K0012 andK0014. The reimbursement for K0010, K0011, and K0012 will be based onMedicaid’s pricing file and fee schedule. Reimbursement for K0014 will be basedon the Manufacturer's Suggested Retail Price (MSRP) minus 15%.• Reimbursement for wheelchair accessories using procedure codes listed inAppendix P under Wheelchair Accessories will be based on Medicaid’s pricing fileand fee schedule.• Repairs and/or replacement of parts for motorized/power wheelchairs will requireprior authorization by the Alabama Medicaid Agency. Prior authorization may begranted for repairs and replacement parts for motorized/power wheelchairs notpreviously paid for by Medicaid and those prior authorized through the EPSDTprogram. Wheelchair repairs and replacement parts for motorized/powerwheelchairs may be covered using the appropriate HCPC code listed in Section14.5.3 under Wheelchair Accessories.• Reimbursement may be made for up to one month for a rental of a wheelchairusing procedure code K0462 while patient owned equipment is being repaired.Deleted:February 1,2003, begancoverage ofAdded:coversAdded:motorized/Power, andDeleted: foradults age 21and aboveDeleted:EffectiveJune 20,2003, begancoveringAdded:coversDeleted:Section14.5.3Added:Appendix PDeleted:Accessoriesfor themotorized…per approvedwheelchairDeleted: A,must haveat least…withNRRTS/RESNADeleted: atleast oneemployee…Supplier(CRTS)Added: musthave…ofNorthAmerica(RESNA)Added: orregisteredwith…Suppliers(NRRTS).Deleted:only, whohaveemployees…provide thatare certifiedmayparticipate.April 2005 14-19
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Chapter 14 Durable Medical Equipment (DME)

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