Chapter 14 Durable Medical Equipment (DME)

Durable Medical Equipment (DME) 14• Recipient must have decubitus ulcer or skin breakdown.• Recipient must be essentially wheelchair confined.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 through the EPSDT Program. The information submitted must includedocumentation that the recipient meets the above medical criteria.Medicaid also reimburses Durable Medical Equipment providers for the RohoCushions for the Extra Heavy Duty Wheelchair. This wheelchair cushion is coveredas a purchase through Medicaid using Medicare’s procedure code K0108. ThisHCPC code may be used to cover wheelchair cushions for obese individuals whocould not use HCPC code E0192.Deleted: EffectiveOctober 1, 2000,began reimbursingAdded: reimbursesNOTE:Medicaid will use the established prior authorization criteria for the Extra HeavyDuty Wheelchair and Roho Cushion, but we will add weight, width and depthspecifications. Individuals approved for these items must be fitted and measured forwheelchair and cushion by the Durable Medical Equipment company providingthese services.NOTE:Purchase of a Low Pressure and Positioning Equalization Pad will be limited to oneevery two years for recipients who meet the above criteria.OxygenOxygen is necessary for life. When we breathe in, oxygen enters the lung and goes intothe blood. When the lungs cannot transfer enough oxygen into the blood to sustain life,an oxygen program may be necessary.Oxygen therapy is a covered service based on medical necessity and requires priorauthorization. Requests for coverage must be received by EDS within thirty calendardays after the oxygen equipment is dispensed. The 30 days will be calculated from thedate the prior authorization request is received by EDS. All prior authorization requestsreceived with a date greater than 30 days from dispensed date will be assigned aneffective date based on actual date received by EDS if the recipient continues to meetmedical criteria. No payment will be made for the days between the dispensed dateand the date assigned by the Prior Authorization Unit. The DME provider will be notifiedin writing of the assigned effective date and additional justification requirements ifapplicable. In order to receive a prior authorization number, forms 360 and 342 must becompleted and submitted to EDS. Oxygen therapy is based on the degree ofdesaturation and/or hypoxemia. To assess patient's need for oxygen therapy, thefollowing criteria must be met:a. The medical diagnosis must indicate a chronic debilitating medical condition,with evidence that other forms of treatment (such as medical and physical therapydirected at secretions, bronchospasm and infection) were tried without success, andthat continuous oxygen therapy is required. Oxygen will not be approved for PRNuse only.b. Recipients must meet the following criteria:April 2005 14-21