Regulation .05 Limitations.
Regulation .05 Limitations.LinkCopy Citation
The Program does not cover:
A.
Incontinency pants and disposable underpads unless the following conditions are met:
(1)
The incontinence supplies are medically necessary for medical conditions associated with prolonged urinary or bowel incontinence;
(2)
For pull-on underwear type garments, the recipient is capable of independently putting on and removing the garment; and
(3)
Disposable incontinence supplies meet, at a minimum, the following absorbent capacity standards:
(a)
For children's diapers and underwear, not less than 800cc;
(b)
For youth diapers and underwear, not less than 1,000cc;
(c)
For small adult diapers and underwear, not less than 1,200cc;
(d)
For medium adult diapers and underwear, not less than 1,750cc;
(e)
For large, extra large, and bariatric adult diapers and underwear, not less than 2,000cc; and
(f)
For disposable underpads, not less than 1,000 cc;
B.
Osteogenesis stimulators unless the following criteria are met:
(1)
The use is for noninvasive therapy;
(2)
The bone fracture is at least 6 months old, except when used for pseudarthrosis; and
(3)
The space gap of the fracture measures 1/2 centimeter or less, except when used for pseudarthrosis;
C.
Osteogenesis stimulators beyond the first 6 weeks of use unless evaluations at the 6-week and 3-month intervals after initial date of service verify recipient use of at least 50 percent of the time prescribed, on a form designated by the Program;
D.
The following durable medical equipment:
(1)
Equipment prescribed primarily to provide comfort or convenience, including, but not limited to, emesis basins, posture support chairs, over-the-bed tables;
(2)
Self-help devices including, but not limited to, grab bars, shower stools, and commode seats;
(3)
Abdominal supports;
(4)
Bed boards;
(5)
Enema bags;
(6)
Environmental controls;
(7)
Exercise equipment and devices, unless home use of such equipment is a necessary component of an active physical therapy program;
(8)
Geriatric chairs;
(9)
Heating pads or lamps;
(10)
Hot water bottles;
(11)
Hydrocollators;
(12)
Ice bags;
(13)
Knee cages;
(14)
Nasal atomizers;
(15)
Restraints;
(16)
Sitz baths;
(17)
Soft collars;
(18)
Whirlpools;
(19)
Whirlpool bath equipment;
E.
Disposable medical supplies and durable medical equipment provided in a facility or by a group when reimbursement is covered by another segment of the Program;
F.
Items which are investigational or experimental in nature;
G.
Nutritional supplements supplied by a DMS/DME provider under this chapter if the provider is also a licensed pharmacy and has a Medicaid Pharmacy provider number;
H.
Food supplements or infant formulas, including enteral nutritional products and supplemental vitamin and mineral products, when administered orally;
I.
Purchase of used equipment, except as approved by the Department as per Regulation .07L of this chapter;
J.
Equipment if the recipient owns or otherwise has access to useable equipment that serves the same purpose as the requested equipment;
K.
Replacement of equipment or a device while the item is still under warranty or before having met the Department’s life expectancy schedule unless prepayment authorization has been obtained.
L.
Replacement of a prosthetic device or component if necessary due to misuse.
M.
Rental of any equipment not in good working condition for the entire length of rental;
N.
Rental of equipment for any period longer than 90 days without renewed documentation of continued medical need from the prescriber for each 90-day period;
O.
Modifications to motor vehicles;
P.
Disposable medical supplies and durable medical equipment ordered by an individual who is not enrolled as a provider in the Program on the date of service; and
Q.
Disposable medical supplies and durable medical equipment ordered by an entity, facility, or other provider that is not an individual.