Current through 2024-38, September 18, 2024
This section describes coverage restrictions and
limitations for Medical Supplies and DME. Changes in technology alone do not
necessitate replacement or upgrades in equipment. If it is medically necessary
for a member to exceed any of the listed limits, the prescribing provider must
submit a request for PA and provide supporting medical documentation to
establish the medical necessity. Unless otherwise specified, limits apply to
all members twenty-one (21) years and older.
60.08-1
Physician Provided
Supplies
Physicians may bill for those medical supplies needed to
perform office procedures, which are above and beyond what is usually included
in a normal office visit. Reimbursement is made on the basis of acquisition
cost only and may not include any additional markup. Physicians must bill under
Chapter II, Section
90, "Physician Services" of the
MaineCare Benefits Manual.
A prescribing provider may not be reimbursed for both
prescribing and supplying DME to the same member, unless the DME is otherwise
unobtainable or the DME typically requires no maintenance or replacement during
the period used by a member. If these circumstances do exist, reimbursement to
the prescribing provider for also supplying DME shall be on the basis of the
acquisition cost of the DME. The prescribing provider must maintain a copy of
the invoice to support such claims. In addition, this policy shall also apply
to any entity in which the provider has direct or indirect proprietary
interest. All transactions are subject to State and Federal restrictions
regarding self-referral.
DME providers may not bill for items delivered to a
member in a prescribing provider's office.
60.08-2
Orthotics and
Prosthetics
The Department requires that orthotic or prosthetic
services be provided by a licensed occupational therapist, a licensed physical
therapist, prosthetist (American Board for Certification), or an accredited
orthotist (Board for Orthotist Certification). PA is required for all custom
molded orthotics and prosthetics regardless of price using evidence-based
criteria and/or criteria based on national standards for evaluating what is
considered medically necessary.
Providers shall warranty prosthetics for a period of one
(1) year to assure proper fit of products purchased by the Department. The
warranty will cover adjustments, repairs, and parts replacement associated with
shrinkage, workmanship, etc.
60.08-3
Augmentative and Alternative
Communication Devices
Members must trial augmentative and alternative
communication devices before the Department will purchase or rent the devices.
PA requests for augmentative and alternative communication devices shall
include information documenting the trial period to determine the
appropriateness and member utilization of the device.
60.08-4
Specially Modified Foods and
Formulas
Specially modified foods and formulas are covered when
the member has inborn errors of metabolism.
60.08-5
Orthopedic Shoes and Other
Supportive Devices for Feet
Orthopedic shoes and other supportive devices for the
feet generally are not covered. However, shoes that are an integral part of a
leg brace, and therapeutic shoes such as those furnished to diabetics, are
covered. For members twenty-one (21) and older, these items are subject to the
following limitations:
A. Items
classified with HCPCS Level II codes as foot inserts, foot arch supports, shoe
wedges or shoe heels are limited to two (2) units (meaning 2 items or 1 pair)
per member per year.
B. Items
classified with HCPCS Level II codes as orthotic footwear, including orthopedic
shoes or items classified as 'other orthopedic footwear', are limited to two
(2) units (meaning 2 shoes or 1 pair) per year.
C. Items classified with HCPCS Level II codes
as shoe lifts are limited to eight (8) units per member per year (units are one
(1) inch increments).
D. Items
classified with HCPCS Level II codes as diabetic footwear including diabetic
shoes and fittings are limited to two (2) units per member per year (meaning 1
pair or 2 fittings). Modifications and inserts for diabetic shoes are limited
to a combined total of six (6) units per member per rolling year.
E. Items classified with HCPCS Level II codes
as repositioning foot orthotics, excluding the words "abduction rotation bar"
are limited to two (2) units (meaning 2 shoes or 1 pair) per year.
60.08-6
Nebulizers
Nebulizers are limited to one per member every five (5)
years for members twenty-one (21) and older.
60.08-7
Incontinence Supplies
A. The monthly service limits for diapers and
other disposable incontinence products for members twenty-one (21) years and
older are as follows:
1. Disposable briefs or
pull ons are limited to eight (8) units per day for adults.
2. Disposable personal pads, large sized
disposable under pads, liners, shields, guards, and undergarments are limited
to one hundred and fifty (150) units per thirty-six (36) day period for
adults.
3. Disposable non-sterile
gloves are limited to 5 boxes (at 100 per box) or 500 gloves per member per
36-day period for adults. Effective January 1, 2019, gloves may be covered if
the member requires a caregiver to change the briefs/pull-ups; this will
require documentation by the prescribing provider in the member's medical
record. If the member is able to change his/her own briefs/pull-ups, then
gloves shall not be covered unless there is a specific medical need for gloves
documented by the prescribing provider in the member's medical
record.
B. Incontinence
supplies are not covered for children under five (5) years of age. If it is
medically necessary for a child age four (4) years and younger to use
incontinent supplies, then a DME provider may submit a request for PA which
must include sufficient supporting medical documentation from the prescribing
provider (i.e., specific medical exam records and supporting medical literature
that shows that the member's medical condition causes incontinence that would
not otherwise be normally expected in this age group) to establish the medical
necessity and a bowel/bladder training program has failed. The request will be
reviewed and decided by the Department or its Authorized Entity.
C. Providers may provide up to a ninety (90)
day supply. Members may refuse to accept more than a thirty-six (36) day
supply.
60.08-8
Power Mobility Devices and Manual Wheelchairs
Reimbursement for Power Mobility Devices (PMDs) requires
PA whether or not the member is eligible for Medicare or other third party
insurance. The PA criteria for PMDs are located on the MaineCare Health PAS
Online Portal.
In the case of motorized wheelchair requests for
Medicare/MaineCare dually eligible members, MaineCare will review the request
and issue a PA decision and the allowable reimbursement rate if approved. The
decision must be issued prior to the purchase of any Power Wheelchair (PWC) or
Power Operated Vehicle (POV), and prior to the submission of any claims to
Medicare. Any price changes for PWCs and POVs that have received Prior
Authorization shall be treated in the same manner as all other price changes on
prior authorized equipment.
A.
Limitations
The following limits apply to members twenty-one (21)
years and older. Providers may submit documentation detailing the need to
exceed the limits, and the Prior Authorization Unit will evaluate the need to
exceed the limit.
1.
Power
Operated Vehicles: Members will be limited to one (1) Power Operated
Vehicle (i.e. scooter) every three (3) years, and cannot upgrade to a power
wheelchair until the three (3) years have lapsed.
2.
Manual or Power Wheelchairs:
Members will be limited to one (1) wheelchair (i.e. manual or Power Wheelchair)
every five (5) years.
B.
General Requirements
1.
Manual or Power Wheelchairs:
Members who meet the eligibility requirements for both a prosthetic device
necessary to allow functional mobility and a power or manual wheelchair must
choose between the prosthetic device and a wheelchair and must sign a letter
exercising their choice. A wheelchair will be provided in the interim on a
rental basis for those members choosing a prosthetic device. Members may seek a
PA for a manual wheelchair in addition to a prosthesis if medically
necessary.
2. Regardless of the
type, only one wheelchair at a time is reimbursable for each member.
3. The primary purpose is not to allow the
member to perform leisure or recreational activities.
4. Reimbursement is allowed for amputee kits
for standard wheelchairs in a NF or ICF- IID. Reimbursement for a wheelchair
with right or lefthanded drive is allowed in case of arm amputee or
paralysis.
5. Limitations of
strength, endurance, range of motion, or coordination, presence of pain, or
deformity or absence of one or both upper extremities are relevant to the
assessment of upper extremity function.
6. An exception to the requirement in Section
60.06-3(F)
may be granted for a member who needs a wheelchair during the winter months but
is unable to make the necessary home modifications due to the frozen
conditions. The provider may not bill the Department for modifications or
structural changes, as they are not a MaineCare-covered DME service.
7. If a member-owned PMD meets coverage
criteria, medically necessary replacement items, including but not limited to
batteries, are covered.
8.
MaineCare does not consider inability to climb stairs a medically necessary
indication for a PMD. A PMD is not considered medically necessary when the sole
purpose is to elevate a person to eye level, to extend a wheelchair user's
reach. In addition, inability to navigate rough terrain outside the home is not
considered a medically necessary indication for a PMD.
9. When requesting a PA for a PMD in a NF or
other setting in which there is continuous supervision, the requesting provider
must document the member's medical necessity to be independently mobile beyond
what can be provided by staff in that setting.
10. The Department will not approve equipment
for purposes other than medical necessity.
C.
Evaluation and Documentation
Requirements
The following evaluation and documentation requirements
must be met for the Department to approve PMDs:
1. The prescribing provider must perform a
face-to-face evaluation with the member and shall refer the member to an
experienced, licensed, MaineCare enrolled physical therapist (PT), occupational
therapist (OT), or other provider who has specific training and experience in
rehabilitation wheelchair evaluations. The prescribing provider shall provide
medical documentation of the medical disease, syndrome, and/or functional
impairment(s) that justify the medical necessity for the equipment and
accessories;
2. The PT/OT shall
conduct an evaluation and provide a signed and dated report that includes
equipment recommendations and identifies the medical disease, syndrome, and
functional impairment(s) that justify the medical necessity for the equipment
and accessories. The PT/OT shall have no financial affiliation with the medical
equipment supplier. Accessories will be approved or denied based on MaineCare
Criteria, as normal;
3. The DME
provider is required to retain the above documentation and a completed and
signed home access report. The documentation should also include a statement
indicating the member is able to transfer safely in and out of the PMD and has
adequate trunk stability to safely ride in the PMD;
4. The DME provider shall obtain a written
prescription for the PMD, signed and dated by the prescribing provider who
performed the face-to-face evaluation, within 45 days of the
evaluation;
5. The DME provider
shall provide documentation to the Department, signed by the member, indicating
that the member has been informed that the member will be limited to one (1)
POV every three (3) years and cannot upgrade to a Power Wheelchair until the
three (3) years have lapsed;
6. The
DME provider shall provide the Department an itemized list of all the medically
necessary items and their cost, as well as the provider's usual and customary
prices for the items;
7.
Documentation of the member's current height and weight are included in the
member's medical record; and
8. The
member must have a letter from his or her physician stating that the member's
condition is not expected to deteriorate significantly for three (3)
years.
60.08-9
Hospital Beds
The following limits apply to members twenty-one (21)
years and older:
A. Reimbursement will
be limited to one (1) hospital bed every five (5) years.
B. Reimbursement will be limited to one (1)
standard mattress (to fit a hospital bed) every two (2) years.
C. Trapeze bars attached to bed will be
limited to two (2) per lifetime.
D.
Cushioned headrest will be limited to one (1) per year.
60.08-10
Other Limitations for Members
Twenty-one (21) years of Age and Older
A. Mattress Pads to include Gel and Dry are
limited to one (1) per year.
B.
Sitz bath is limited to one (1) per year.
C. Canes are limited to one (1) per
year.
D. All walkers are limited to
one (1) per year.
E. All commodes
are limited to two (2) per five (5) year period.
F. Bath/shower chairs are limited to one (1)
per five (5) year period.
G.
Bath/tub wall rail is limited to two (2) per three (3) year period.
H. Raised toilet seat is limited to two (2)
per three (3) year period.
I. Cough
stimulating device is limited to two (2) per year.
J. All types of Intermittent Positive
Pressure Breathing (IPPB) devices are limited to once per lifetime.
K. Ultrasonic and Aerosol compressors with
Small Volume Nebulizers (SVNEB) are limited to one (1) per year.
L. Patient lift sling or seat is limited to
one (1) per year.
M. Hydraulic
patient lift is limited to two (2) per lifetime.
N. Transcutaneous Electrical Nerve Stimulator
(TENS) units/treatment systems are limited to one (1) per year.
O. Pneumonic Compression Devices (used to
lymphedema and chronic venous insufficiency) are limited to one (1) device per
year.
P. Apnea monitors are limited
to one (1) per year.
Q. Respiratory
suction pumps (home model, portable or stationary, electric), when purchased,
are limited to one (1) per member every three (3) years; if paid for on a
rental basis, the physician must document therapeutic benefit for renewal after
ninety (90) days.
60.08-11
Continuous Positive Airway
Pressure (CPAP) and Bi-level Positive Airway Pressure (Bi-PAP) Devices
The Department requires sleep studies done within the
three (3) years preceding the initial request to document the need for a CPAP
and Bi-PAP device. All CPAP and Bi-PAP devices will be rented on a three- (3)
month trial basis to determine appropriateness and member utilization. CPAP and
Bi-PAP devices and supplies are limited to the following quantities for members
under twenty-one (21):
A. Oral/nasal
mask - one (1) per three (3) months
B. Oral cushion - two (2) per one (1)
month
C. Nasal pillow - two (2) per
one (1) month
D. Full face mask -
one (1) per three (3) months
E.
Facemask interface - one (1) per one (1) month
F. Nasal interface - two (2) per one (1)
month
G. Head gear - one (1) per
six (6) months
H. Chin strap - one
(1) per six (6) months
I. Tubing -
one (1) per one (1) month
J. Tubing
(with heating element) - one (1) per three (3) months
K. Filter (disposable) - two (2) per one (1)
month
L. Filter (non-disposable) -
one (1) per six (6) months
M. Oral
interface - one (1) per three (3) months
N. Exhalation port - one (1) per twelve (12)
months
O. Water chamber - one (1)
per one (1) month
P. Humidifier -
one (1) per five (5) years
Q. C-PAP
- one (1) per five (5) years
R.
Bi-PAP - one (1) per five (5) years
60.08-12
Hearing Aids
Hearing aids shall be purchased from a licensed
audiologist or hearing aid dealer & fitter, utilizing a vendor contracted
with the State of Maine's Division of Procurement Services. For more
information, please visit the Division of Procurement Service's hearing aids
contracts webpage. Members shall trial hearing aids for a trial period of at
least thirty (30) days. Following the trial period, the audiologist or hearing
aid dealer & fitter will provide written confirmation that the hearing aid
meets the member's need and should be purchased.
A. Hearing aid accessories are not required
to be purchased under contract.
B.
Hearing aids are subject to the following limitations:
1. Members twenty-one (21) years and older
are limited to one (1) hearing aid or one (1) replacement pair every five (5)
years.
2. For members under the age
of twenty-one (21), replacements are allowed once per year as medically
necessary and as identified and referenced in the MaineCare Benefits
Manual, Section
94.05-2.
C. Six (6) replacement batteries
are allowed per month.
D. Back up
or spare hearing aids and/or repairs to backup or spare hearing aids are not
covered.
60.08-13
Dispense of Disposable Medical Supplies
The Department shall authorize dispense of up to a ninety
(90) day supply of items considered to be disposable medical supplies when
medically necessary and all prior authorization approval has been obtained. The
Department considers disposable medical supplies to include breast milk bags
and incontinence, urological, ostomy, diabetic, and CPAP and Bi-PAP
supplies.
60.08-14
Breast Milk Bags
Breast Milk Bags are limited to 120 units (bags) per
member per rolling month.
60.08-15
Automatic Blood Pressure
Monitors
Automatic Blood Pressure Monitors are limited to one unit
per member per three (3) calendar years.
60.08-16
Electric Breast Pumps and
Supplies
Effective October 25, 2023, in accordance with
22 MRS
3174-KKK, electric breast pumps and supplies
are covered without prior authorization or limitation when they are prescribed
by a Qualified Provider.
