Current through Register No. 40, October 3, 2024
The following items shall not be covered:
(a) Items that do not meet the coverage
criteria set forth in
He-W
571.04;
(b) Specialty formulas when not needed for
life-sustaining purposes, or as the sole source of nutrition, except as allowed
under He-W 546;
(c) Common,
over-the-counter, household and medicine-chest items that can be purchased
without a prescription, including, but not limited to:
(1) Corn plasters and foot pads;
(2) Nursery supplies;
(3) Hand cleaners or sanitizers, such as
Hygenall or Purell;
(4) Personal
hygiene items including body lotions, toothbrushes, electric shavers, razors,
and other hair removal devices and services;
(5) Thermometers;
(6) Odor barrier products;
(7) Toileting wipes, except as allowed by
He-W
571.04(c) (18) above;
(8) First aid kits and supplies, including
adhesive bandages and scissors;
(9)
Mechanical heated water circulating pads and pumps, including hydrocollator
heating units;
(10) Non-legend
medications specified in accordance with
He-W
570.05(d) ; and
(11) Nutritional supplements or formula as
follows:
a. Dietary or food
supplements;
b. Lactose-free foods
or products that aid in lactose digestion;
c. Gluten-free products;
d. Low carbohydrate diets;
e. Weight-loss foods, formulas, and related
products intended to aid in weight loss;
f. Normal grocery items, including over-the
counter infant formulas;
g. Baby
food and banked breast milk;
h.
Grocery items that can be prepared in a blender and used with an enteral
feeding system;
i. High protein
powders and mixes;
j. Medical food
products that:
1. Are prescribed without a
diagnosis requiring such foods;
2.
Used for convenience purposes;
3.
Have no proven therapeutic benefit without an underlying disease, condition, or
disorder;
4. Used as a substitute
for acceptable standard dietary interventions; or
5. Are used exclusively for nutritional
supplementation; and
k.
Enteral nutrition when the recipient has food allergies or dental problems, but
has the ability to meet his or her nutritional requirements through an
alternative store-bought food source;
(d) Environmental modifications and controls,
including:
(1) Wheelchair ramps;
(2) Tub rails;
(3) Space heaters and heat lamps;
(4) Air conditioners and fans;
(5) Air purifiers, including HEPA and vacuum
filters;
(6) Vaporizers,
humidifiers, and dehumidifiers;
(7)
Aromatherapy;
(8) Stairway lifts
and elevators;
(9) Lifting devices
including electric patient lifts and hydraulics and ceiling tract lifting
devices;
(10) Power generators;
and
(11) Adaptive or computer
switch toys;
(e) Items
typically not used by the general public for a medical purpose, including:
(1) Furniture for non-mobility purposes
including, but not limited to:
a. Corner
seats;
b. Positioning
chairs;
c. High chairs or other
feeding type chairs;
d. All beds,
except hospital beds as allowed by
He-W
571.04(c) (20) c., and the pediatric
specialty beds as allowed in
He-W
571.04(c) (20) above;
e. Toddler beds, bassinets, portable cribs,
or playpens; and
f. Massage and
therapy tables and related equipment;
(2) Lumbar support cushions;
(3) Bedding, including electric or weighted
blankets;
(4) Clothing items,
including sportswear such as neoprene shorts;
(5) Hot Tubs, whirlpool equipment, aqua
massagers, and sauna baths;
(6)
Recreational, therapeutic, or exercise equipment including, but not limited to,
bicycles, treadmills, weights, tables, mats, and swings; and
(7) Video, computer games, or computer
applications intended for the purpose of exercise, recreation, education, or
instruction;
(f) Items
that contribute to or enhance fertility or procreation;
(g) Items typically used by the general
public for preventing injury or ensuring safety, including:
(1) Car seats, except as allowed by
He-W
571.04(d) (1) ;
(2) Helmets, including protective helmets
used for sports and recreation, except as allowed by
He-W
571.04(d) (2) ; and
(3) Pneumatic vests and lumbar
supports;
(h) Disposable
incontinence supplies for:
(1) Recipients
younger than 3 years of age, except as allowed by He-W 546; and
(2) Recipients 21 years of age or older who
do not meet the criteria set forth in
He-W
571.04(c) (18) ;
(j) Sleep positioning wraps;
(k) Computer controlled and programmable
lateral rotation therapy bed systems;
(l) Chewelry, and similar non-toxic jewelry,
intended to be chewed;
(m) Magnets,
crystals, gemstones, and similar non-evidenced based, experimental, or
investigational healing items;
(p) Automated
medication reminder systems;
(q)
Cast bags, such as Aquashield;
(r)
Electric resuscitators and portable defibrillators;
(s) Bi-directional static progressive stretch
devices, including, but not limited to, Joint Active Systems (JAS)
splints;
(t) Service or therapy
animals and related expenses;
(u)
Apnea monitors, except when the criteria in
He-W
571.04(c) (2) have been
met;
(v) Prosthetic fingers,
thumbs, and toes when not part of a covered prosthesis;
(w) Commercially available
strollers;
(x) Wheelchairs
requested within 24 months of the purchase of a customized stroller;
(y) The following accessories and options for
wheelchairs, customized strollers, or other mobility devices:
(1) Wheelchair remote controls and attendant
control switches;
(2) Power assist
devices or equipment to modify a manual wheelchair into a power
wheelchair;
(3) Air suspension
systems;
(4) Power standers and
seat lift mechanisms;
(5) Grade
aids and anti-roll devices for manual wheelchairs;
(6) Wheelchairs with stair climbing
options;
(7) Titanium framed and
sport-type wheelchairs;
(8) Custom
wheels for off-road use or for sport and recreational purposes;
(9) Any wheelchair accessory or option for
purposes of allowing the recipient to perform leisure, social, or recreational
activities;
(10) Lights, horns,
mirror, baskets, pouches, backpacks, and similar accessories; and
(11) Back-up or spare wheelchairs for
recipients who already have a wheelchair, power scooter, or customized
stroller;
(z) Any
back-up or spare equipment, with the exception of ventilators;
(aa) Replacement, repair, or modifications of
an item when the need for which is the result of:
(1) Recipient abuse, misuse, or
neglect;
(2) Failure to protect the
item from the elements;
(3) Using
the item inappropriately or contrary to its designed and intended
use;
(4) Making improper repairs to
the item, which would void any manufacturer's warranty;
(5) Loss of the item when basic safeguarding
measures could have been instituted;
(6) Failure to maintain the item through
proper routine maintenance by an authorized dealer; or
(7) Taking any action that would otherwise
void the manufacturer's written warranty or is contrary to the manufacturer's
recommendations for care, use, and maintenance;
(ab) Repairs, modifications, or adjustments
to any rented item, including wheelchairs;
(ac) Repairs to recipient owned items, when
the recipient does not meet the criteria for coverage of the item, or when such
repairs, modifications, or adjustments are:
(1) Within the dispensing provider's or
manufacturer's warranty; or
(2)
Within one year of the purchase of the item or accessory, unless written
documentation from the provider demonstrates a significant change in the
recipient's medical condition that meets the coverage criteria for the item and
the repair or modification is warranted;
(ad) Upgrades to or replacement of any
functioning item that still meets the recipient's needs, but is being requested
solely as a result of changing technology;
(ae) Items which are more costly than other
available items which could be expected to provide the same, similar, or
duplicate outcome;
(af) Any items
that are primarily intended for use at a school, are part of a child's care
plan at school, and could be obtained through the "Medicaid to Schools" program
in accordance with He-M 1301, and the child and the child's school participate
in the "Medicaid to Schools" program; and
(ag) Any items that are experimental,
investigational, or non-FDA approved.
(See Revision Note at chapter heading He-W 500); ss by
#6158, eff 12-29-95, EXPIRED: 12-29-03
New. #8961, eff 8-20-07; amd by
#8983, INTERIM, eff 9-21-07, EXPIRES: 3-19-08; amd by #9103, eff 3-12-08; amd
by #9637, eff 1-16-10; amd by #9836, eff
12-18-10