Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) Manual

Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) Manual

Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically, and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.

Update Log

Publication History

This publication supersedes all previous Durable Medical Equipment, Orthotics, Prosthetics and Supplies (DMEOPS) handbooks. Published by the Montana Department of Public Health & Human Services, January 2005.

Updated January 2005, April 2005, September 2007, June 2008, July 2012, October 2013, November 2014, April 2015, August 2015, January 2016, July 2016, January 2017, May 2017, October 2017, January 2020, March 2020, December 2020, and December 2021.

CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.

Update Log

12/27/2021

• Therapeutic Continuous Glucose Monitors (CGM) Devices and Sensors - K0554 & K0553
• Diapers, Underpads, Liners/Shields
• Sterile and Non-Sterile Gloves
• E0470 and E0471 Respiratory Assist Devices (RAD)
• Home Ventilators E0465, E0466, and E0467

12/09/2020

• Cranial Remolding Orthotics/Helmets, Code S1040 added to the Covered Services chapter.
• DME Prescription Requirements updated.
• Covered Services chapter was divided into two chapters: the Covered Services chapter and the Non-Covered Services chapter.
• Removed obsolete fax numbers from the Prior Authorization chapter and added a link to the Qualitrac  portal for DME prior authorization requests.
• Removed obsolete form for DMEPOS Medical review from Appendix A: Forms.

03/25/2020

• Updated the Prior Authorization chapter with current prior authorization contractor information and policy.
• Updated the Covered Services chapter with updated requirements for most devices covered and alphabetized the covered items under both the general list and the EPSDT list.

01/01/2020

• Cost Sharing removed from the How Payment is Calculated chapter.
• Medicaid replaced with "Montana Healthcare Programs" in all chapters.

10/16/2017
Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) Manual converted to an HTML format and adapted to 508 Accessibility Standards.

07/28/2016
DMEPOS, July 2016: In summary, the Hospital Grade Breast Pump section was updated in the Covered Services chapter, and the Table of Contents and Index was changed to reflect impacted page numbers.
 
06/20/2016
DMEPOS, July 2016: In summary, date only was amended on the cover, and the How Payment is Calculated section was updated to reflect the current cost share amount.

12/31/2015
DMEPOS, January 2016: HELP plan-related updates and others

09/01/2015
DMEPOS, August 2015: URL Updates and Covered Services

04/24/2015
DMEPOS, April 2015: Covered Services, Billing Procedures, and Appendix A: Forms

11/19/2014
DMEPOS, November 2014: Entire Manual
The entire manual has been streamlined; sections that include text changes are noted with black bar in margin.

11/15/2013
DMEPOS, October 2013: Entire Manual
These replacement pages also include a terminology change (client to member). Unless a paragraph also included content changes, it is not marked as a change but is included in this document.

07/26/2012
DMEPOS, July 2012: Appendix A: Forms

06/14/2010
DMEPOS, June 2010: Covered Services

11/26/2008
DMEPOS, June 2008: Covered Services

03/05/2008
DMEPOS, September 2007: Covered Services and Submitting a Claim

04/07/2005
DMEPOS, April 2005: Removed CPAP CMN

01/21/2005
DMEPOS, January 2005: Apnea Monitor PA Requirements

End of Update Log Chapter

Table of Contents

Introduction

Prior Authorization

Covered Services

Non-Covered Services 

Billing Procedures

How Payment Is Calculated

Appendix A: Forms

End of Table of Contents Chapter

Introduction

Thank you for your willingness to serve members of the Montana Healthcare Programs and other medical assistance programs administered by the Department of Public Health and Human Services.

This manual provides information specifically for providers of Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS). Other essential information for providers is contained in the separate General Information for Providers Manual. Providers are responsible for reviewing both manuals.

Rule References

Providers must be familiar with all current Montana Healthcare Programs rules and regulations governing the Montana Healthcare Programs. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rule references are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office.

Providers are responsible for knowing and following current Montana Healthcare Programs rules and regulations.

The following rules and regulations are specific to the DMEPOS program.

• Administrative Rules of Montana (ARM)
  • ARM 37.86.1801 – ARM 37.86.1807 Prosthetic Devices, Durable Medical Equipment and Medical Supplies

End of Introduction Chapter

Prior Authorization

What Is Prior Authorization?

To ensure federal funding requirements are met, certain items/services are reviewed before delivery to a Montana Healthcare Programs member. These items/services are reviewed for appropriateness based on the member’s medical need. In determining medical appropriateness of an item/service, the Department or designated review organization may consider the type or nature of the service, the provider of the service, the setting in which the service is provided and any additional requirements applicable to the specific service or category of service.

Prior authorization will be required if the item/service has a reimbursement amount equal to or greater than $1,000.00 or the Manufacturers Suggested Retail Price (MSRP) is greater than $1,334.00.

When requesting prior authorization, remember:

• Only Montana Healthcare Programs enrolled DMEPOS providers may request prior authorization for items/services.
• In circumstances where another insurance carrier is primary and payment has been made, prior authorization is not required unless reimbursement is equal to or greater than $1,000.00 or the MSRP is equal to or greater than $1,334.00.
• Documentation must support medical necessity.
• Documentation must coincide with other documentation provided by those involved with the member.
• Documentation must be complete, including appropriate signatures and dates.
• Member must be eligible for Montana Healthcare Programs.
• Use the correct CMN for the item/service (if required).
• Use current correct coding.
• Use the appropriate place of service, 12 (Home) or 32 (Nursing Facility). See the Place of Service Code Set on the CMS website: https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html

Montana Healthcare Programs does not pay for services when prior authorization requirements are not met.

Do not submit a prior authorization request solely for denial in order to receive payment from another source. Instead, provide the requesting payer with documentation supporting noncoverage of the item (e.g., provider manuals, provider notices, newsletters). You may request the documentation from Provider Relations.

To request prior authorization for an item/service:

• Submit prior authorization requests to Mountain-Pacific Quality Health, the Department's utilization review contractor,through the Qualitrac web portal at the following link: https://www.mpqhf.org/corporate/medicaid-portal-home/medicaid-portal-document-library/.
• Include appropriate supporting documentation with the request.

Granting of prior authorization does not guarantee payment for the item/service.

Upon completion of the review, the member and requesting provider are notified. The provider receives an authorization number that must be included on the claim. If the requesting provider does not receive the authorization number within 10 business days of being notified of the review approval, the requesting provider may call Mountain-Pacific Quality Health (MPQH) at (877) 443-4021.

For the prior authorization criteria for DME, see below or on the Prior Authorization Information link in the left menu on the Provider Information website.

Prior Authorization Information

Durable Medical Equipment (DME) Prior Auth Contact:

MPQH
(406) 457-3060 Helena
(877) 443-4021 Long-distance

Documentation Requirements:

Medical necessity documentation must include all of the following:

• Completed DMEPOS Prior Authorization Request  through the Qualitrac Portal.
• Supporting documentation, which must include at a minimum:
  • Prescription
  • Certificate of medical need (if required for the item)
  • Narrative summary from the prescribing authority detailing the need for the item
  • A manufacturers retail price sheet and product warranty information

For members being treated by a licensed therapist, a copy of the member’s plan of care in relation to the item/service is required; video if possible.

End of Prior Authorization Chapter

Covered Services

General Coverage Principles

This chapter provides covered services information that applies specifically to services and supplies provided by Durable Medical Equipment, Prosthetic, Orthotic and Medical Supply (DMEPOS) providers. Like all healthcare services received by Montana Healthcare Programs members, services rendered by these providers must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers Manual.

Montana Healthcare Programs follows Medicare’s coverage requirements for most items. A Medicare manual is available from the Durable Medical Equipment Regional Carriers (DMERC) website, https://med.noridianmedicare.com/web/jddme. Montana Healthcare Programs considers Medicare Region D DMERC medical review policies as the minimum DMEPOS industry standard. This manual covers criteria for certain items/services which are either in addition to Medicare requirements or are services Medicare does not cover.

Montana Healthcare Programs coverage determinations are a combination of Medicare Region D DMERC policies, Centers for Medicare and Medicaid Services (CMS), national coverage decisions (NCDs), local coverage determinations (LCDs), and Department designated medical review decisions. DMEPOS providers are required to follow specific Montana Healthcare Programs policy or applicable Medicare policy when Montana Healthcare Programs policy does not exist. When Medicare makes a determination of medical necessity, that determination is applicable to the Montana Healthcare Programs.

Provision of Services (ARM 37.86.1802)

Federal regulations require that items/services covered by the Department are reasonable and necessary in amount, duration, and scope to achieve their purpose. DMEPOS items/supplies must be medically necessary, prescribed in writing, and delivered in the most appropriate and cost-effective manner, and may not be excluded by any other state or federal rules or regulations.

Supplier Documentation (ARM 37.86.1802)

All covered DMEPOS items for members with Montana Healthcare Programs as the primary payer, must be prescribed by a physician or other licensed practitioner of the healing arts within the scope of the provider’s practice as defined by state law. A prescription or order must include the member's name or Medicaid identification number; order date; general description of the item or HCPCS code or HCPCS code narrative, or a brand name and model number; quantity to be dispensed, if applicable; treating practitioner's name or national provider identifier; and treating practitioner's signature. Prescriptions for oxygen must also include the liter flow per minute, hours of use per day and the member’s PO2 or oxygen saturation blood test results. If applicable, an order for durable medical equipment must list separately all concurrently ordered options, accessories, or additional features that are separately billed or require an upgrade code. If applicable, an order for medical supplies must include all concurrently ordered supplies that are separately billed, listing each separately.

DMEPOS suppliers must obtain a written prescription in accordance with ARM 37.86.1802. Suppliers should also maintain documentation showing the member meets the Medicare coverage criteria.

ARM 37.86.1802 describes how prescriptions/orders can be transmitted. The rule refers providers to the Medicare guidelines. Prescriptions can be oral, faxed, or hard copy. For items that are dispensed based on a verbal order, the supplier must obtain a written order that meets the requirements in Chapter 3 of the Medicare Supplier Manual. The rule refers to current Medicare rules and regulations in the Region D Medicare Supplier Manual (including the most current LCDs). Chapters 3 and 4 of the Medicare Suppliers Manual outline the documentation requirements for suppliers.

Although a prescription is required, coverage decisions are not based solely on the prescription. Coverage decisions are based on objective, supporting information about the member’s condition in relation to the item/service prescribed. Supporting documentation may include but is not limited to (if applicable) a Certificate of Medical Necessity (CMN), DME Information Form (DIF), and/or a physician’s, therapist’s or specialist’s written opinion/attestation for an item/service based on unique individual need.

The member’s medical record must contain sufficient documentation of the member's medical condition to substantiate the necessity for the prescribed item/service. The member’s medical record is not limited to the physician’s office records. It may include hospital, nursing home, or home health agency records and records from other professionals including, but not limited to, nurses, physical and occupational therapists, prosthetists, and orthotists. It is recommended that suppliers obtain (for their files) sufficient medical records to determine whether the member meets Montana Healthcare Programs coverage and payment rules for the particular item.

Proof of delivery is required in order to verify that the member received the DMEPOS item. Proof of delivery documentation must be made available to the Department upon request. Montana Healthcare Programs does not pay for delivery, mailing or shipping fees or other costs of transporting the item to the member’s residence.

The effective date of an order/script is the date in which it was signed.

Providers must retain the original prescription, supporting medical need documentation and proof of delivery. For additional documentation requirements, see the General Information for Providers Manual, Provider Requirements chapter, and Chapters 3 and 4 of the Medicare Supplier Manual.

Certificate of Medical Necessity

For a number of DMEPOS items, a certificate of medical necessity (CMN) is required to provide supporting documentation for the member’s medical indications. Montana Healthcare Programs adopts the CMNs used by Medicare DMERCs, approved by the Office of Management and Budget (OMB), and required by CMS.

These forms are available on the websites listed below:

• Provider Information website, https://medicaidprovider.mt.gov/forms
• CMS website, http://www.cms.gov
• Noridian website, https://med.noridianmedicare.com/web/jddme

The following is a list of items that require a CMN and the corresponding form. This reference list will be updated as changes are made. If any discrepancies exist between these referenced forms and what is published by CMS and Medicare, the CMS and Medicare policy shall take precedence. See Chapter 4 of the Medicare Supplier Manual.

Certificate of Medical Necessity (CMN) Forms

Item:  Lymphedema Pumps (Pneumatic Compression Devices)
Form:  CMS-846   Form Date:  06/2019

Item:  Osteogenesis Stimulators
Form:  CMS-847   Form Date:  06/2019

Item:  Oxygen
Form:  CMS-484  Form Date:  12/2018

Item:  Seat Lift Mechanisms
Form:  CMS-849  Form Date:  06/2019

Item:  Section C Continuation Form
Form:  CMS-854  Form Date:  06/2019

Item:  Transcutaneous Electrical Nerve Stimulators (TENS)
Form:  CMS-848  Form Date:  06/2019

DME Information Forms

Item:  External Infusion Pumps
Form:  CMS-10125  Form Date:  06/2019

Item:  Enteral and Parental Nutrition
Form:  CMS-10126  Form Date:  06/2019

Rental/Purchase (ARM 37.86.1801–1806)

The rental period for items identified by Medicare as capped, routine, or inexpensive are limited to 13 months of rental reimbursement. After 13 months of continuous rental, the item is considered owned by the member and the provider must transfer ownership to the member. Total Montana Healthcare Programs rental reimbursement for items listed in Medicare’s capped rental program or classified by Medicare as routine and inexpensive rental are limited to the purchase price for that item listed on the Montana Healthcare Programs fee schedule. If purchasing the rental item is cost effective, the Department may cover the purchase of the item. See Chapter 5 of the Medicare Supplier Manual.

A statement of medical necessity for rental of DME equipment must indicate the length of time the equipment is needed, and all prescriptions must be signed and dated.

Servicing

During the 13-month rental period, Montana Healthcare Programs rental payment includes all supplies, maintenance, repair, components, adjustments, and services related to the item during the rental month. Separately billable supply items identified and allowed by Medicare are also separately billable to Montana Healthcare Programs under the same limitations. No additional amounts related to the item may be billed or reimbursed for the item during the 13-month period. During the rental period, the supplier providing the rental equipment is responsible for all maintenance and service. After the 13-month rental period when ownership of the item is transferred to the member, the provider may bill Montana Healthcare Programs for the supplies, maintenance, repair components, adjustment and services related to the items. Montana Healthcare Programs does not cover repair charges during the manufacturer’s warranty period.

Items classified by Medicare as needing frequent and substantial servicing are covered on a monthly rental basis only. The 13-month rental limit does not apply, and rental payment may continue as long as the item is medically necessary.

Interruptions in rental period

Interruptions in the rental period of less than 60 days will not result in the start of a new 13-month period or new purchase price limit. Periods in which service is interrupted do not count toward the 13-month rental limit.

Change in supplier

A change in supplier during the 13-month rental period will not result in the start of a new 13-month period or new purchase price limit. Providers are responsible for investigating whether another supplier has been providing the item to the member; Montana Healthcare Programs does not notify suppliers of this information. The provider may rely upon a separate written member statement that another supplier has not been providing the item, unless the provider has knowledge of other facts or information indicating that another supplier has been providing the item. The supplier providing the item in the 13th month of the rental period is responsible for transferring ownership to the member.

Change in equipment

If rental equipment is changed to different but similar equipment, the change will result in the start of a new 13-month period or new purchase price limit only when all of the following are met:

• The change in equipment is medically necessary as a result of a substantial change in the member’s medical condition.
• A new certification of medical necessity for the new equipment is completed and signed by a physician.

No more than one month’s medical supplies may be provided to a member at one time.

Coverage of Specific Services

The simplest way to verify coverage for a specific service is to check the Department’s fee schedule for your provider type. Fee schedules are available on the Provider Information website.

In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers Manual and in this chapter. Use the fee schedule in conjunction with the detailed coding descriptions in the CPT and HCPCS coding books that pertain to the date of service.

The following are specific criteria for certain items/services which are either in addition to Medicare requirements or are services Medicare does not cover.

Billing of Miscellaneous Code B9998

Supplies listed below that are included in the daily kits but billed with B9998 will be denied. Providers should review supplies being billed with the miscellaneous code and bill according to the following guidelines.

Medicare Coding Guidelines

The codes for enteral feeding supplies (B4034–B4036) include all supplies, other than the feeding tube itself, required for the administration of enteral nutrients to the member for one day.

Codes B4034–B4036 describes a daily supply fee rather than a specifically defined kit. Some items are changed daily; others may be used for multiple days. Items included in these codes are not limited to prepackaged kits bundled by manufacturers or distributors.

These supplies include, but are not limited to, feeding bag/container, flushing solution bag/container, administration set tubing, extension tubing, feeding/flushing syringes, gastrostomy tube holder, dressings (any type) used for gastrostomy tube site, tape (to secure tube or dressings), Y connector, adapter, gastric pressure relief valve, declogging device, etc.

These items must not be separately billed using the miscellaneous code (B9998) or by using specific codes for dressings or tape. The use of member items may differ from member-to-member and from day-to-day.

Blood Glucose Monitors and Related Supplies

For blood glucose monitors and related supplies, the Department will follow the criteria set forth in the LCD for glucose monitors (L33822):

1. The member has diabetes mellitus or gestational diabetes; and
2. The physician has provided the member (or the member’s caregiver) with adequate training for the device prescribed.

Montana Healthcare programs will allow the following for test strips and lancets:

Members who are not insulin dependent are allowed up to 100 test strips and up to 100 lancets every 3 months if the above criteria have been met.

Members who are insulin dependent are allowed up to 300 test strips and up to 300 lancets every 3 months if the above criteria have been met.

High Utilization

For both members who are not insulin dependent or insulin dependent and require more than the allowed number of test strips and lancets every 3 months, high utilization will be covered if the criteria (a)-(c) below have been met. 

1. Basic coverage criteria (1)-(2) listed above are met; and
2. The treating physician has seen the member, evaluated their diabetes control within 6 months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, and has documented in the member's medical record the specific reason for the additional materials for that particular member; and
3. If refills of quantities of supplies that exceed the utilization guidelines are dispensed, there must be documentation in the physician's records (e.g., a specific narrative statement that adequately documents the frequency at which the member is actually testing or a copy of the member’s log) that the member is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the member is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months.

Providers submitting claims with units considered high utilization must ensure all of the above requirements for high utilization are met. To process claims for high utilization members, the procedure below shall be followed:

• Indicate any associated insulin use in the appropriate field using ICD-10 code Z79.4. If this code is not present, the claim will be denied. 
• If the high utilization claim is for a child age birth through 20, a "1" must be entered in column H (EPSDT) on the CMS-1500 paper claim form or a "Y" must be entered in the SV-111 field within the 837 electronic. claim format. This will enable the claim to bypass the edit for over the usual allowable units without rejection or denying the claim first.

Insulin Pumps E0784

Insulin pumps do not require prior authorization.  DME providers are reminded before providing insulin pumps to covered Montana Healthcare Programs members, the member must meet the Medicare coverage criteria. The coverage criteria are outlined in the External Infusion Pumps local coverage determination (LCD) located on the Noridian website. https://med.noridianmedicare.com/documents/2230703/7218263/External+Infusion+Pumps+LCD+and+PA.

For enrolled members ages 0-20 only, the criteria for insulin pumps and supplies is not subject to Medicare's criteria outlined above. The criteria for this age group is that the member is insulin dependent.

Therapeutic Continuous Glucose Monitor (CGM) Devices and Sensors – K0554 & K0553

Montana Healthcare Programs covers therapeutic continuous glucose monitor (CGM) devices that are classified by CMS as “therapeutic CGMs” for members ages 4 and up without prior authorization. Children under the age of 4 will require prior authorization.

Not all products marketed as CGM devices are considered therapeutic CGMs.

A therapeutic CGM is one that meets the definition of DME and is labeled by the Food & Drug Administration (FDA) for non-adjunctive use (i.e., it can be used to make treatment decisions without the need for a stand-alone home blood glucose monitor (BGM) to confirm testing results).

Therapeutic CGMs and related supplies are covered when all of the following coverage criteria below (1-5) are met:

1. The member has diabetes mellitus; and
2. The member is insulin-treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and
3. The member’s insulin treatment regimen requires frequent adjustment by the member on the basis of BGM or CGM testing results; and
4. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the member to evaluate their diabetes control and determined that criteria (1-3) above are met; and
5. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in person visit with the member to assess adherence to their CGM regimen and diabetes treatment plan.

When a therapeutic CGM (code K0554) is covered, the related supply allowance (code K0553) is also covered.

A therapeutic CGM system replaces a standard BGM and related supplies. During the time a CGM is being billed with the associated supply allowance, Montana Healthcare Programs will no longer pay separately for the BGM and supplies.

All therapeutic CGM devices billed to Montana Healthcare Programs using HCPCS code K0554 must be listed on the Data Analysis and Coding (PDAC) Product Classification List for HCPCS code K0554.

If any of coverage criteria (1-5) are not met, the CGM and related supply allowance will be denied as not reasonable and necessary.

Supplies for Therapeutic CGM Devices

Montana Healthcare Programs pays a supply allowance for supplies used with a therapeutic CGM system. For K0553, one (1 unit) supply allowance is payable per 30 days and encompasses all items necessary for the use of the device. Items deemed necessary for use of the device include, but are not limited to, CGM sensor, CGM transmitter, home BGM and related BGM supplies (test strips, lancets, lancing device, calibration solutions) and batteries. Sufficient supplies must be provided to the member to last at least 30 days of therapy. K0553 must not be used for supplies used with CGM coded as A9278.

• Only one (1) UOS of code K0553 may be billed to the DME MACs at a time.
• Billing more than one (1) UOS per 30 days for code K0553 will be denied as not reasonable and necessary.

Non-Therapeutic CGM Devices, Codes A9278, A9277, and A9276

Code A9278 (Receiver (monitor); external, for use with interstitial continuous glucose monitoring system) describes any CGM system that fails to meet the DME Benefit requirements as described in CMS Ruling 1682R. A device that requires the additional use of a stand-alone home BGM to make treatment decisions to confirm testing results.

Products not listed on the Data Analysis and Coding (PDAC) Product Classification List for HCPCS code K0554 do not meet the requirements for a therapeutic CGM and must be coded as A9278.

Code A9276 (Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply) and code A9277 (Transmitter; external, for use with interstitial continuous glucose monitoring system) describe the supplies used with a non-therapeutic CGM. Codes A9276 and A9277 are not used to bill for supplies used with code K0554.

Non-Therapeutic CGM Criteria

Non-therapeutic CGMs and related supplies require prior authorization and will be covered by Montana Healthcare Programs under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit for eligible Montana Healthcare Programs members if the following coverage criteria below (1-4) are met:

1. Member is under the age of 21; and
2. Member has a diagnosis of insulin dependent diabetes mellitus; and
3. Clinically documented compliance with diabetes management plan, with current clinical notes dated within 90 days; and
4. Patient and/or parent education provided on proper use of the device.

Submit prior authorization requests to Mountain-Pacific Quality Health through the Qualitrac Web Portal. Providers will need to select EPSDT when submitting PA requests.

For continuation of supplies the following criteria must be met:

1. Clinically documented compliance with diabetes management plan.
2. Continued use of the CGM.

Please note:
Montana Healthcare Programs allows 30 units per month for items coded as A9276 and 1 unit every 6 months for items coded as A9277.

• All clinical documentation must be dated within 90 days of the member receiving the device or supplies.
• Members 3 years of age and under who meet the above criteria will be reviewed by MPQH on a case-by-case basis.

Breast Pumps

Double Electric Breast Pumps for Purchase E0603

Double electric breast pumps are covered for all eligible Montana Healthcare Programs members who are at least 28 weeks gestation, or currently breastfeeding. Montana Healthcare Programs has a sole source provider, Healthy Babies, Happy Moms. 

The ordering process is a two-part process.

1. Member must go online and order their breast pump online at Montana Medicaid Breast Pumps — Healthy Babies, Happy Moms Inc.
2. Providers must send prescriptions to Healthy Babies, Happy Moms Inc. via fax to (844) 276-5457. The prescription template is available on the Healthy Babies, Happy Moms website.

Providers are reminded that prescriptions must include the following: 

• Member name 
• Member ID 
• Date of birth 
• Order date 
• Printed name and signature of authorized provider 
• Valid diagnosis code for a pregnant member or for a nursing member 
• Estimated due date or gestational age 
• Medical necessity 
• Projected length of need 
• Member's mailing address 
• Member's phone number 

All orders will be delivered within 5 business days from the receipt of a fully completed order, which includes prescription from authorized provider and patient's online order. Pumps can only be provided to a member who is at least 28 weeks pregnant or is breastfeeding. 

Please note: 

• Only one breast pump will be provided per pregnancy and no more than one breast pump will be provided per year. 

For more information regarding Healthy Babies, Happy Moms Inc. and information regarding breast pumps available through Medicaid please see the following website: https://www.MontanaMedicaidBreastpumps.com.

Hospital Grade Electric Breast Pump Rentals E0604 RR:

Hospital grade electric breast pump rentals are a covered service if at least one of the following criteria has been met:

• Member has a preterm infant of 39 weeks or less gestation
• Infant has feeding difficulties due to a neurological or physical condition that impairs adequate suckling
• Illness of member and/or infant that results in their separation
• Member is on a mediation that compromises her milk supply; or
• Member has multiple infants.

Hospital grade electric breast pump rental is limited for 2 months, unless additional months are prior authorized by Mountain-Pacific Quality Health through the Qualitrac portal. https://www.mpqhf.org/corporate/medicaid-portal-home/medicaid-portal-document-library/. Montana Healthcare Programs payment may not be provided through the infant’s eligibility.

Combination Shower Commode Chairs and Accessories, Screening Criteria

Use HCPCS Code E0240 when submitting prior authorization request and/or when billing for the shower commode chair. This code does require prior authorization and must meet the criteria listed below:

Description

A combination shower commode chair is used to meet a member's toileting and hygiene needs.

Indications for coverage of the shower commode chair

All of the following criteria must be met:

• Unable to use a standard conventional toilet.
• Unable to get in/out of the shower independently and is unable to sit or stand in the bath/shower independently.
• Home assessment determines that shower/tub access is possible for the requested equipment.
• Home assessment determines that once the equipment is in the shower/tub enclosure caregiver access to the member is adequate.
• Documentation to support that a less costly system will not meet the needs of the member.

Indications for coverage of the tilt/recline feature

Documentation to support the medically necessity for the member to be in a tilt/recline position for toileting or showering.

Indications for coverage of a non-standard seating system

• Current decubitus that is a stage 3 or 4; and
• Shower/commode chair needed for a minimum of 30 minutes or longer; or
• No decubitus and use of the shower/commode chair for a minimum of 2 hours or longer per toileting session.

Indications for coverage of foot plates

No functional use of the lower limbs.

Indications for coverage of elevating leg rests

Musculoskeletal condition which prevents 90-degree flexion of the knee or meets medical necessity for the tilt/recline feature on the shower/commode chair.

Indications for coverage of a heavy-duty shower/commode chair

Documentation from a medical resource of the member's weight to determine justification for the requested chair.

Compression Garments for the Legs

Inflatable compression garments, non-elastic binders, or personally fitted prescription gradient compression stockings are considered medically necessary for members who have any of the following medical conditions:

• Treatment of any of the following complications of chronic venous insufficiency:
  • Lipodermatosclerosis
  • Stasis dermatitis (venous eczema)
  • Varicose veins (except spider veins)
  • Venous edema
  • Venous ulcers (stasis ulcers)
• Edema accompanying paraplegia, quadriplegia
• Edema following surgery, fracture, burns, or other trauma
• Members with lymphedema
• Post sclerotherapy (applies only to pre-made or custom-made pressure gradient support stockings)
• Post-thrombotic syndrome (post-phlebetic syndrome)
• Postural hypotension
• Prevention of thrombosis in immobilized members (e.g., immobilization due to surgery, trauma, general debilitation)
• Severe edema in pregnancy

Compression garments for the legs are considered experimental and investigational for all other indications (e.g., management of spasticity following stroke) and will not be covered.

Replacements

Are considered medically necessary when the compression garment cannot be repaired or when required due to a change in the member’s physical condition. For pressure gradient support stockings, no more than 4 replacements per year are considered medically necessary for wear.

Two pairs of compression stockings are considered medically necessary in the initial purchase. The second pair is for use while the first pair is in the laundry. For a list of covered compression stocking codes, see the fee schedule on the Provider Information website.

Custom-Made Equipment, Prosthetics, or Orthotics

DME must be billed using the date of service the member receives the equipment or item.

The only exception is in the case of custom-made equipment, prosthetics, or orthotics. In these instances, the date when the item is casted, molded, and/or fitted may be used. Before a provider can bill for any custom-made equipment, prosthetic or orthotic, the work on the item must be complete and the member must have signed the delivery ticket.

Because Montana Healthcare Programs eligibility is determined on a month-to-month basis, providers must check eligibility before an item is ordered or work has begun and document the member’s eligibility in their file.

Only one unit of service may be billed for any one day. Units of service in excess of one per day will be rejected as incorrect coding. 

Gastrostomy/Jejunostomy Tube, Code B4088

This code has been incorrectly profiled in the HCPCS coding book. The code is described as just a tube, when in fact it is a complete kit. The manufacturer will not supply the tube separate from the kit. Medicare currently reimburses code B4088 as a tube, but suppliers are billed by the manufacturer for the complete kit. Therefore, the reimbursement to the suppliers is not adequate in comparison to the cost for the complete kit.

Montana Healthcare Programs recognizes the constraints this has put on suppliers when providing this item to members. Effective immediately, Montana Healthcare Programs will reimburse code B4088 at 75% of the Manufacturer’s Suggested Retail Price (MSRP) in accordance with ARM 37.86.1807.

Incontinence Supplies

Diapers, Underpads, Liners/Shields

• Diapers, underpads, and liners/shields are covered for members who have a medical need for the items based on their diagnosis.
• These items are not covered for members under 3 years of age or members in long-term care (nursing facility) settings.
• Montana Healthcare Programs limits the number of incontinent products distributed by product type:
  
  • Disposable diapers are limited to 180 diapers per month.
  • Disposable under pads liners/shields are limited to 240 per month.
  • Reusable diapers, under pads, liner/shields are limited to 36 units each per year (3 per month).

Sterile and Non-Sterile Gloves

Both sterile and non-sterile gloves are considered incontinence supplies only.

• Gloves are covered for members who have a medical need for the items based on their diagnosis (i.e., diagnosis is incontinence).
• Sterile gloves (A4930) are billed per pair.
• Non-sterile gloves (A4927) are billed per box.
• Gloves are reimbursed at 75% of the Manufacturers Suggested Retail Price (MSRP).
• For gloves without MSRP, providers may submit their Usual and Customary (U&C) charge as long as it does not exceed 50% of their acquisition cost.

The T codes listed below are more specific to the type of incontinence products being distributed by Montana Healthcare Programs DME providers:

Incontinence Products HCPCS Codes

Code: T4521   Description:  Adult sized disposable incontinence product, brief/diaper, small, each

Code: T4522   Description:  Adult sized disposable incontinence product, brief/diaper, medium, each

Code: T4523   Description:  Adult sized disposable incontinence product, brief/diaper, large, each

Code: T4524   Description:  Adult sized disposable incontinence product, brief/diaper, extra-large, each

Code: T4525   Description:  Adult sized disposable incontinence product, protective underwear/pull-on, small, each

Code: T4526   Description:  Adult sized disposable incontinence product, protective underwear/pull-on, medium, each

Code: T4527   Description:  Adult sized disposable incontinence product, protective underwear/pull-on, large, each

Code: T4528   Description:  Adult sized disposable incontinence product, protective underwear/pull-on, extra-large, each

Code: T4529   Description:  Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each

Code: T4530   Description:  Pediatric sized disposable incontinence product, brief/diaper, large size, each

Code: T4531   Description:  Pediatric sized disposable incontinence product, protective underwear/pull-on, small/medium size, each

Code: T4532   Description:  Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each

Code: T4533   Description:  Youth sized disposable incontinence product, brief/diaper, each

Code: T4534   Description:  Youth sized disposable incontinence product, protective underwear/pull-on, each

Code: T4535   Description:  Disposable liner/shield/guard/pad/ undergarment, for incontinence, each

Code: T4536   Description:  Incontinence product, protective underwear/pull-on, reusable, any size, each

Code: T4537   Description:  Incontinence product, protective underpad, reusable, bed size, each

Code: T4539   Description:  Incontinence product, diaper/brief, reusable, any size, each

Code: T4540   Description:  Incontinence product, protective underpad, reusable, chair size, each

Code: T4541   Description:  Incontinence product, disposable underpad, large, each

Code: T4542   Description:  Incontinence product, disposable underpad, small size, each

Code: T4543   Description:  Disposable incontinence product, brief/diaper, bariatric, each

Prosthetic Devices

HCPCS codes L5000-L7520, L8040-L8515, and L8630-L8670 no longer require prior authorization.

In accordance with Administrative Rules of Montana (ARM) 37.86.1802, Montana Medicaid has adopted Medicare coverage criteria for Medicare covered durable medical equipment as outlined in the Region D Supplier Manual, local coverage determinations (LCDs) and national coverage determinations (NCDs).

Providers are reminded that members must meet the Medicare coverage criteria. The criteria can be found at the following documentation checklists and at the following Noridian website: https://med.noridianmedicare.com/web/jddme/policies/lcd/active.
 
Lower Limb Prostheses - LCD 33787 Documentation Checklist: https://med.noridianmedicare.com/documents/2230703/6750839/Documentation+Checklist+-+Lower+Limb+Prostheses

Facial Prostheses - LCD 33738
 
Eye Prostheses - LCD 33737
 
External Breast Prostheses  - LCD 33317   Documentation Checklist: https://med.noridianmedicare.com/documents/2230703/6750839/Documentation+Checklist+-+External+Breast+Prostheses
 
Upper Extremity Prostheses - Criteria can be found in Section 120 of the Medicare Benefit Policy Manual, Chapter 15: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf.

Respiratory Devices

Apnea Monitors - Infants 

See the Respiratory Devices section under Children’s (EPSDT) Coverage Criteria for Specified DME  of this chapter below.

Bi-level Positive Airway Pressure Devices (Bi-Pap) E0470 – E0471

Bi-level positive airway pressure device with back-up rate, does not require prior authorization.  Providers are reminded of the following Medicare LCD L33718 medically necessary criteria that must be met in order for Medicaid reimbursement to include: 

E0470 Obstructive Sleep Apnea: 

A. The member must have a face-to-face clinical evaluation by the treating practitioner prior to the sleep test to assess the member for obstructive sleep apnea. 
B. The member must have a sleep test (as defined below) that meets either of the following criteria (1 or 2): 

1. The Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events;
   OR 
2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
   1. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or
   2. Hypertension, ischemic heart disease, or history of stroke. 

C. The member and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.  
D. A single-level continuous positive airway pressure device (E0601) has been tried and proven ineffective based on a therapeutic trial conducted in ether a facility or in a home setting.

E0470 and E0471 Respiratory Assist Devices (RAD): 

For an E0470 or an E0471 RAD to be covered, the treating physician must fully document in the member's medical record symptoms characteristic of sleep-associated hypoventilation, such as daytime hypersomnolence, excessive fatigue, morning headache, cognitive dysfunction, dyspnea, etc.

A RAD (E0470 or E0471) is covered for those beneficiaries with one of the following clinical disorders:  

• Restrictive thoracic disorders (i.e., neuromuscular diseases or severe thoracic cage abnormalities)
• Severe chronic obstructive pulmonary disease (COPD)
• CSA or CompSA
• Hypoventilation syndrome

Items coded as E0470 and E0471 do not require prior authorization if the coverage criteria are met.

Home Oxygen Therapy for Members Residing in Skilled Nursing Facility

In accordance with ARM 37.86.1802, Montana Healthcare Programs has adopted Medicare coverage criteria for Medicare covered durable medical equipment as outlined in the Region D Supplier Manual, Medicare Supplier Manual, and local and national coverage determinations (LCDs and NCDs).

For prosthetic devices, durable medical equipment, and medical supplies not covered by Medicare, coverage will be determined by the Department and published on the Department’s fee schedule in accordance with ARM 37.86.1807.

The Department will follow criteria set forth in the LCD for Oxygen and Oxygen Equipment (L11457) for members residing in a skilled nursing facility. The only exception is that the Department will allow oximetry tests ordered by a physician and performed by qualified nursing personnel at the skilled nursing facility as an acceptable blood gas study. To be reimbursed for this service, DME providers shall follow all other criteria set forth in L11457.

Montana Healthcare Programs Policy on 36-Month Oxygen Cap

To preserve member access, Montana Healthcare Programs will not be following the Medicare 36-month cap policy on oxygen for Montana Healthcare Programs-only members. This policy will include eligible Montana Healthcare Programs nursing home dual-eligible (both Medicare and Montana Healthcare Programs coverage) members for Medicare non-covered oxygen. Montana Healthcare Programs pays only Medicare co-insurance and deductibles up to the Montana Healthcare Programs allowable for QMB-only members. The Department will follow established policy for this member group. For example, once the 36-month cap starts, Medicare rules apply, and the Department will follow.

Dual-eligible members will follow the 36-month cap as outlined by Medicare rules. Montana Healthcare Programs members with QMB and SLMB do not have Montana Healthcare Programs oxygen coverage. Montana Healthcare Programs will follow all of the Medicare oxygen changes outlined in the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 except for the 36-month cap as stated above.

Home Ventilators E0465, E0466, and E0467

The following documentation requirements apply for both invasive and non-invasive home ventilators and should be submitted with each prior authorization request.

Requirements for initial home ventilator requests:

• Ordering Health Care Provider/Prescriber (HCP) notes detailing the diagnosis for which the ventilator is required. This is to include diagnoses such as progressive neuromuscular disease, thoracic restrictive conditions, cardiac conditions, COPD, upper airway conditions, and other causes of respiratory failure.
• The HCP’s notes must document why less costly alternatives such as simple oxygen therapy, maximal medical management, bilevel and/or other respiratory assistive devices, etc., are not suitable. This might be because they were tried and failed, they are inappropriate for the patient's condition with an explanation as to why, or some other specific reason why less costly alternatives will not meet the patient’s needs.
• The notes must include objective data such as blood gas measurements, Pulmonary Function Test (PFT), oximetry, sleep study interpretations, and any other laboratory and diagnostic imaging that supports the need for home ventilation. This does not mean that absolute lab or test values will be used for authorization. It means that the ordering HCP’s judgment, informed by the objective data will be the ultimate determinant of need.
• The original prescription from the ordering HCP.
• A Detailed Written Order (DWO)* must also be provided: This includes:
  
  • Estimated length of need – this may be undetermined but might also vary in the case of convalescence from an exacerbation of a condition
  • Hours of use
  • Ventilator settings

*A prescription alone that does not include this information will not be sufficient.

After initial approval:

Prescribers shall determine the frequency of follow-up assessments. Providers must document all updated orders and/or information regarding treatment in the medical record. Providers are reminded, in accordance with 42 CFR 440.70, the need for medical supplies, equipment, and appliances should be identified by the prescriber and reviewed at least annually. Face-to-face assessments of the patient by the prescriber can be performed using telemedicine. Telemedicine guidance can be found in the General Information for Providers Manual.

To renew a prior authorization:

• A recent order by the treating physician/practitioner for refills; or
• A recent change in prescription; or
• Timely documentation in the member's medical record showing usage of the item.

• Timely documentation in the member’s medical record showing usage of the item.
• Supplier records such as compliance logs or service plans.
• Supplier records documenting member confirmation of continued use.

Ventilators are not subject to the 13-month rental period. Ventilators are reimbursed as a rental only.

Wheelchairs

In addition to the Medicare Region D DMERC Medical Review Policies for wheelchairs, to meet the needs of a particular member, various wheelchair options or accessories are typically selected. The addition of options or accessories does not deem the wheelchair as a custom wheelchair.

Wheelchairs in Nursing Facilities

Nursing facilities are expected to make available wheelchairs with typical options or accessories in a range of sizes to meet the needs of its members. If a typical option or accessory is not available for a currently owned nursing facility wheelchair, an accommodating wheelchair is expected to be made available by the nursing facility. Only wheelchairs (including power chairs) that cannot be reasonably used by another nursing home member will be considered for purchase. Wheelchairs must be used primarily for mobility. Roll-about chairs which cannot be self-propelled are specifically designed to meet the needs of ill, injured, or otherwise impaired members and are considered similar to wheelchairs. Roll-about chairs may be called by other names such as transport or mobile geriatric chairs (geri chairs). Roll-about chairs are not wheelchairs; however, many of the same options and accessories can be found for use on them. Like standard wheelchairs, roll-about chairs are expected to be available to Members by the nursing facility.

Wheelchair Seating in the Nursing Facility

Indications and limitations for a wheelchair seating system for an existing wheelchair such as a facility wheelchair, member owned wheelchair or a donated wheelchair. The seating system would be the least costly alternative that is able to be adapted to meet the positioning needs of a member in a nursing home and will be covered if there is a comprehensive written evaluation by a licensed clinician who is not an employee of or otherwise paid by a supplier.

Included in the evaluation referenced above are the following:

• Seating systems for increased independence
• Documentation must support all of the following:
  • The member must be able to self-propel to specific destinations (e.g., to and from the dining room, to and from the activity room).
  • Be able to do a functionally independent task as a result of the seating system such as feed self.
  • The member must be evaluated to determine that he/she is able to safely self-propel and does not have the potential cause harm.
• Be alert and oriented and capable of being completely independent in use of the wheelchair after adapted seating system is placed.

OR

• Seating systems for positioning purposes
• Seating for positioning purposes will be reviewed on a case-by-case basis.
• Documentation must support that all other less costly alternatives have been ruled out, to include but not be limited to use of the following:
  • Use of mobile geriatric chairs (geri chairs) provided by nursing home and use of standard off-the-shelf seating products have been tried and ruled out; and
  • Use of rolled towels, blankets, pillows, wedges, or similar devices by facility caregivers to reasonably position and reposition member; and
  • Documentation that has determined that nursing staff is unable to accomplish repositioning by any other means while the member is up and out of bed; and member is not incapacitated to the point that he/she is bedridden.

Children’s (EPSDT) Coverage Criteria for Specified DME

ARM 37.86.2201 allows for coverage of a durable medical equipment (DME) item/service that is typically considered non-covered, does not meet coverage criteria, or is over the Montana Healthcare Programs allowable units if the item/service is determined medically necessary for an eligible child under 21.

Bowel Management Program Supplies for EPSDT Children Ages 0-20

For the Enema Bowel Program, the child must:
Have failed a trial of oral medications for chronic constipation AND has ONE or more of the following:

• History of excessive stool retention
• History of painful or hard bowel movements
• Presence of a large fecal mass in the rectum

Supplies covered:

• Foley catheters with 30cc balloon
• Medline enema bags/gravity bags
• Lubricant, non-sterile
• 30-60cc luer lock syringes

For the Appendicostomy/Cecostomy Supplies, the child must:
Have had an appendicostomy/cecostomy.

Supplies covered:

• Chait trapdoor
• Chait access adapter tube
• Enema bags/gravity bags
• 60cc catheter tip syringes

Gait Trainers - EPSDT Only 

A gait trainer (GT) is a device used to support a member during ambulation. Criteria for coverage of GT include:

• The member's age is 0-20.
• The member is unable to ambulate independently with a standard front or reverse walker because of the need for postural support, due to a chronic neurological condition including abnormal movement patterns, poor balance, poor endurance, or other clearly documented reasons.
• The anticipated functional benefits of walking are not attainable with the use of a walker.
• Must demonstrate tolerance for standing and weight bearing through the lower extremities.
• Potential benefits to the member of assisted walking must be clearly documented as follows:
• The member must be involved in a therapy program established by a physical therapist. The program must include measurable documented objectives and functional goals related to the member and equipment that includes a written carry over plan to be utilized by the member and/or caregiver. The equipment must match the user’s needs and ability level.
• The member has had a trial of the requested GT and the member shows compliance, willingness, and ability to use the GT in the home.
• Video of member using the requested GT home demonstrating ability to use GT by showing potential for progress to meet goals and objectives.

Ketone Test Strips, Codes A4250 and A4252

The following HCPCS codes will be covered for Montana Healthcare Programs children ages 0-20 only, who are at immediate risk for diabetic ketoacidosis:

• A4250, Urine test or reagent strips or tablets (100 tablets or strips)
• A4252, Blood ketone test or reagent strip, each

The member must have a diabetes mellitus or gestational diabetes diagnosis code.

MDI Spacers (EPSDT), Code A4627

A spacer device will be allowed for a child if he/she is using metered dose inhalers prescribed by his/her physician for medication delivery, and the spacer is medically necessary.

If the above criteria are met, the item does not require prior authorization. Montana Healthcare Programs will reimburse this code at 75% of the Manufacturer’s Suggested Retail Price (MSRP), in accordance with ARM 37.86.1807.

Nebulizers/Nebulizer Kit (EPSDT), Codes E0570 RR and A7005

Nebulizers and supplies should be considered for in-home treatment of children when prescribed by their medical provider and when the child has been diagnosed with acute bronchiolitis or respiratory syncytial virus (RSV).

The nebulizer and supplies should be considered for a rental of prescribed length of need as indicated by the provider; typically, 1–3 months.

If the above criteria are met, the item does not require prior authorization.

Phototherapy (Bilirubin) Light with Photometer, Code E0202 RR

The E0202 RR will be reimbursed for infants ages 0-1. One unit of service is billed for each day and units billed are not to exceed a 5-day limit. To assure correct coding, providers are encouraged to refer to the current HCPCS coding manual. DMEPOS suppliers must obtain a written prescription in accordance with ARM 37.86.1802. Suppliers should also maintain supporting documentation showing the member meets the Montana Healthcare Programs coverage criteria. 

Orthotics (EPSDT), Codes L3002, L3010, L3020, and L3040

Devices and instruments to help a child maintain his/her level of mobility, correct physical issues, or decrease pain should be considered when prescribed by their medical provider and the following conditions apply. This list is not all-inclusive, and each case is determined on a case-by-case review of medical necessity:

• Knee or hip subluxation, dislocation
• Spastic movement
• Correct, limit or prevent deformities
• Low-tone pronation (fallen arches, outward-turned foot due to muscle weakness)
• High-tone pronation (high arch, outward-turned foot due to increased muscle tone)
• Swing-phase inconsistency (erratic movements in the foot)
• Drop-foot (drop of the front of the foot due to weakness)
• Eversion (outward turn)
• Inversion (inward turn)

If the child is not having symptoms or pain associated with the above conditions, foot orthotics are not considered medically necessary.

If the above criteria are met, the item does not require prior authorization.

Respiratory Devices for Children (EPSDT)

Apnea Monitors - Infants

The rental of an apnea monitor will be covered initially for a six-month period from the date of the physician’s order. Apnea monitors are covered under at least one of the following conditions:

• A sibling has died from SIDS.
• Infant has symptomatic apnea.
• Observation of apparent life-threatening events (ALTE).
• Infant is on oxygen.
• Symptomatic apnea due to neurological impairment.

For coverage after the initial six-month period, additional months coverage must be prior authorized by the Department and the following conditions must exist and be documented by the physician:

• Infant continues to have significant alarms. (Log must be kept on file.)
• Unresolved symptomatic apnea.

Pulse Oximetry for Children Age 0-20

The capped rental of a Pulse Oximetry Meter (E0445) will no longer require prior authorization for children age 0-20 when all of the following criteria are met:

• The member has a chronic, progressive respiratory or cardiovascular condition that requires continuous or frequent oxygen therapy.
• Oxygen need varies from day to day or per activity (e.g., feeding, sleeping, movement), and a medical need exists to maintain oxygen saturation within a very narrow range in which unpredictable, sub therapeutic fluctuations of oxygen saturation levels occur that cannot be clinically determined and have an adverse effect if not treated.
• A trained caregiver is available to respond to changes in oxygen saturation.
• Montana Healthcare Programs will only reimburse for a capped rental if the above criteria are met. Therefore, the purchase of a pulse oximeter will not be approved for reimbursement.  

Continuous read oximetry meters and any meter used for diagnostic purposes are not covered.

Pulse Oximeter Probes (EPSDT), Code A4606

If a child has a pulse oximeter that was paid for by Montana Healthcare Programs, a replacement probe (A4606) will be covered if the pulse oximeter is still medically necessary and prescribed by their medical provider.

If above criteria are met, the item does not require prior authorization. Montana Healthcare Programs will reimburse this code at 75% of the Manufacturer’s Suggested Retail Price (MSRP), in accordance with ARM 37.86.1807.

Oral Nutrition

Montana Healthcare Programs may cover oral nutritional products for members under the age of 21 who have had an EPSDT screen resulting in a diagnosed medical condition that impairs absorption of a specific nutrient. The member must also have a measurable nutrition plan developed by a nutritionist and the member’s primary care provider (PCP). Use modifier -BO when nutrition is orally administered, not by a feeding tube (only for members under age 21).

Oral Food Thickener (EPSDT), Code B4100

The addition of a thickening agent should be considered medically necessary when prescribed by his/her medical provider and the following diagnosis applies:

• Oropharyngeal dysphagia;
• Reflux disease; or
• Any diagnosis that indicates child is at risk for life threatening aspiration.

If the criteria are met, the item does not require prior authorization. Montana Healthcare Programs will reimburse this code at 75% of the Manufacturer’s Suggested Retail Price (MSRP), in accordance with ARM 37.86.1807.

Cranial Remolding Orthotics/Helmets (EPSDT), Code S1040

Prior authorization is not required for cranial remolding orthotics if the following criteria has been met:

For Members 0-6 Months Old

1. Documented moderate to severe deformational or positional plagiocephaly by physical examination or imaging.
2. Continued deformity after at least two months of parent or caregiver education and at least two months of physical therapy or occupational therapy.

For Members 6-18 Months Old

1. Documented moderate to severe deformational or positional plagiocephaly by physical examination or imaging.

If a member has had craniosynostosis surgery, then S1040 is approved for all age groups without the trial conservative therapies.

End of Covered Services Chapter

Billing Procedures

Using the Montana Healthcare Programs Fee Schedule

When billing Montana Healthcare Programs, it is important to use the Department’s fee schedule for your provider type in conjunction with the detailed coding descriptions listed in the current CPT and HCPCS coding books. In addition to covered services and payment rates, fee schedules often contain helpful information such as appropriate modifiers. Fee schedules are available on the Provider Information website.

Place of Service

Place of service must be entered correctly on each line. Montana Healthcare Programs typically reduces payment for services provided in hospitals and ambulatory surgical centers since these facilities typically bill Montana Healthcare Programs separately for facility charges.

For a list of place of service codes for professional claims, see the link under Coding/Place of Service Codes at http://www.cms.gov/Medicare/Medicare.html.

Date of Service

The date of service for custom molded or fitted items is the date upon which the provider completes the mold or fitting and either orders the equipment from another party or makes an irrevocable commitment to the production of the item.

Rental

Payment includes the entire initial month of rental even if actual days of use are less than the full month. Payment for second or subsequent months is allowed only if the item is used at least 15 days in such months.

End of Billing Procedures Chapter

How Payment Is Calculated

Overview

Although providers do not need the information in this chapter in order to submit claims to Montana Healthcare Programs, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.

Usual and Customary Charge (ARM 37.85.406 and ARM 37.86.1806)

Providers should bill Montana Healthcare Programs their usual and customary charge for each service; that is, the same charge that is made to other payers for that service. The amount of the provider’s usual and customary charge may not exceed the reasonable charge usually and customarily charged by the provider to all payers. For DMEPOS providers, a charge is considered reasonable if it is less than or equal to the manufacturer’s suggested list price.

For items without a manufacturer’s suggested list price, the charge is considered reasonable if the provider’s acquisition cost from the manufacturer is at least 50% of the charge amount. For items that are custom fabricated at the place of service, the amount charged will be considered reasonable if it does not exceed the average charge of all Montana Healthcare Programs providers by more than 20%.

Payment for DMEPOS Items/Services (ARM 37.86.1807)

Payment for DMEPOS is equal to the lowest of either the provider’s usual and customary charge for the item or the Montana Healthcare Programs fee schedule amount in effect for the date of service.

Montana Healthcare Programs payment is equal to 100% of Medicare Region D fee schedule for current procedure codes where a Medicare fee is available, less applicable incurment and/or other applicable fees. Generic or miscellaneous procedure codes are excluded from the Medicare fee schedule. Payment for such excluded procedure codes is 75% of the provider’s submitted charge. For all other procedure codes where no Medicare fee is available, payment is 75% of the submitted charge.

Rental Items

If the purchase of a rental item is cost effective in relation to the member’s need of the item, the purchase may be negotiated. The purchase price would be the amount indicated on the applicable fee schedule less previous payments made to the provider of the item.

Total Montana Healthcare Programs rental reimbursement for items listed in Medicare’s capped rental program or classified by Medicare as routine and inexpensive rental is limited to the purchase price for that item. Monthly rental fees are limited to 10% of the purchase for the item, limited to 13 monthly payments. Interruptions in the rental period of less than 60 days do not result in the start of a new 13-month period or new purchase price limit, but periods during which service is interrupted will not count toward the 13-month limit.

How Payment Is Calculated on TPL Claims

When a member has coverage from both Montana Healthcare Programs and another insurance company, the other insurance company is often referred to as third party liability or TPL. In these cases, the other insurance is the primary payer (as described in the Member Eligibility and Responsibilities chapter of the General Information for Providers Manual), and Montana Healthcare Programs makes a payment as the secondary payer.

How Payment is Calculated on Medicare Crossover Claims

When a member has coverage from both Montana Healthcare Programs and Medicare, Medicare is the primary payer as described in the Member Eligibility and Responsibilities chapter of the General Information for Providers Manual. Montana Healthcare Programs then makes a payment as the secondary payer. For the provider types covered in this manual, the Montana Healthcare Programs payment is calculated so that the total payment to the provider is either the Montana Healthcare Programs allowed amount less the Medicare paid amount or the sum of the Medicare coinsurance and deductible, whichever is lower. This method is sometimes called “lower of” pricing.

End of How Payment Is Calculated Chapter

Appendix A: Forms

See the Forms page of the Provider Information website for the forms listed below.

Certificates of Medical Necessity

• Lymphedema Pumps (Pneumatic Compression Devices) (CMS-846)
• Osteogenesis Stimulators (CMS-847)
• Oxygen (CMS-484)
• Seat Lift Mechanisms (CMS-849)
• Section C Continuation Form (CMS-854)
• Transcutaneous Electrical Nerve Stimulators (TENS) (CMS-848)

DME Information Forms

• External Infusion Pumps DME 09.03 (CMS-10125)
• Enteral and Parenteral Nutrition DME 10.03 (CMS-10126)

End of Appendix A: Forms Chapter

End of Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) Manual

Update Log

Publication History

This publication supersedes all previous Durable Medical Equipment, Orthotics, Prosthetics and Supplies (DMEOPS) handbooks. Published by the Montana Department of Public Health & Human Services, January 2005.

Updated January 2005, April 2005, September 2007, June 2008, July 2012, October 2013, November 2014, April 2015, August 2015, January 2016, July 2016, January 2017, May 2017, October 2017, January 2020, March 2020, December 2020, and December 2021.

CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.

Update Log

12/27/2021

• Therapeutic Continuous Glucose Monitors (CGM) Devices and Sensors - K0554 & K0553
• Diapers, Underpads, Liners/Shields
• Sterile and Non-Sterile Gloves
• E0470 and E0471 Respiratory Assist Devices (RAD)
• Home Ventilators E0465, E0466, and E0467

12/09/2020

• Cranial Remolding Orthotics/Helmets, Code S1040 added to the Covered Services chapter.
• DME Prescription Requirements updated.
• Covered Services chapter was divided into two chapters: the Covered Services chapter and the Non-Covered Services chapter.
• Removed obsolete fax numbers from the Prior Authorization chapter and added a link to the Qualitrac  portal for DME prior authorization requests.
• Removed obsolete form for DMEPOS Medical review from Appendix A: Forms.

03/25/2020

• Updated the Prior Authorization chapter with current prior authorization contractor information and policy.
• Updated the Covered Services chapter with updated requirements for most devices covered and alphabetized the covered items under both the general list and the EPSDT list.

01/01/2020

• Cost Sharing removed from the How Payment is Calculated chapter.
• Medicaid replaced with "Montana Healthcare Programs" in all chapters.

10/16/2017
Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) Manual converted to an HTML format and adapted to 508 Accessibility Standards.

07/28/2016
DMEPOS, July 2016: In summary, the Hospital Grade Breast Pump section was updated in the Covered Services chapter, and the Table of Contents and Index was changed to reflect impacted page numbers.
 
06/20/2016
DMEPOS, July 2016: In summary, date only was amended on the cover, and the How Payment is Calculated section was updated to reflect the current cost share amount.

12/31/2015
DMEPOS, January 2016: HELP plan-related updates and others

09/01/2015
DMEPOS, August 2015: URL Updates and Covered Services

04/24/2015
DMEPOS, April 2015: Covered Services, Billing Procedures, and Appendix A: Forms

11/19/2014
DMEPOS, November 2014: Entire Manual
The entire manual has been streamlined; sections that include text changes are noted with black bar in margin.

11/15/2013
DMEPOS, October 2013: Entire Manual
These replacement pages also include a terminology change (client to member). Unless a paragraph also included content changes, it is not marked as a change but is included in this document.

07/26/2012
DMEPOS, July 2012: Appendix A: Forms

06/14/2010
DMEPOS, June 2010: Covered Services

11/26/2008
DMEPOS, June 2008: Covered Services

03/05/2008
DMEPOS, September 2007: Covered Services and Submitting a Claim

04/07/2005
DMEPOS, April 2005: Removed CPAP CMN

01/21/2005
DMEPOS, January 2005: Apnea Monitor PA Requirements

End of Update Log Chapter

Table of Contents

Introduction

Prior Authorization

Covered Services

Non-Covered Services 

Billing Procedures

How Payment Is Calculated

Appendix A: Forms

End of Table of Contents Chapter

Introduction

Thank you for your willingness to serve members of the Montana Healthcare Programs and other medical assistance programs administered by the Department of Public Health and Human Services.

This manual provides information specifically for providers of Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS). Other essential information for providers is contained in the separate General Information for Providers Manual. Providers are responsible for reviewing both manuals.

Rule References

Providers must be familiar with all current Montana Healthcare Programs rules and regulations governing the Montana Healthcare Programs. Provider manuals are to assist providers in billing Montana Healthcare Programs; they do not contain all Montana Healthcare Programs rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rule references are available on the Provider Information website. Paper copies of rules are available through the Secretary of State’s office.

Providers are responsible for knowing and following current Montana Healthcare Programs rules and regulations.

The following rules and regulations are specific to the DMEPOS program.

• Administrative Rules of Montana (ARM)
  • ARM 37.86.1801 – ARM 37.86.1807 Prosthetic Devices, Durable Medical Equipment and Medical Supplies

End of Introduction Chapter

Prior Authorization

What Is Prior Authorization?

To ensure federal funding requirements are met, certain items/services are reviewed before delivery to a Montana Healthcare Programs member. These items/services are reviewed for appropriateness based on the member’s medical need. In determining medical appropriateness of an item/service, the Department or designated review organization may consider the type or nature of the service, the provider of the service, the setting in which the service is provided and any additional requirements applicable to the specific service or category of service.

Prior authorization will be required if the item/service has a reimbursement amount equal to or greater than $1,000.00 or the Manufacturers Suggested Retail Price (MSRP) is greater than $1,334.00.

When requesting prior authorization, remember:

• Only Montana Healthcare Programs enrolled DMEPOS providers may request prior authorization for items/services.
• In circumstances where another insurance carrier is primary and payment has been made, prior authorization is not required unless reimbursement is equal to or greater than $1,000.00 or the MSRP is equal to or greater than $1,334.00.
• Documentation must support medical necessity.
• Documentation must coincide with other documentation provided by those involved with the member.
• Documentation must be complete, including appropriate signatures and dates.
• Member must be eligible for Montana Healthcare Programs.
• Use the correct CMN for the item/service (if required).
• Use current correct coding.
• Use the appropriate place of service, 12 (Home) or 32 (Nursing Facility). See the Place of Service Code Set on the CMS website: https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html

Montana Healthcare Programs does not pay for services when prior authorization requirements are not met.

Do not submit a prior authorization request solely for denial in order to receive payment from another source. Instead, provide the requesting payer with documentation supporting noncoverage of the item (e.g., provider manuals, provider notices, newsletters). You may request the documentation from Provider Relations.

To request prior authorization for an item/service:

• Submit prior authorization requests to Mountain-Pacific Quality Health, the Department's utilization review contractor,through the Qualitrac web portal at the following link: https://www.mpqhf.org/corporate/medicaid-portal-home/medicaid-portal-document-library/.
• Include appropriate supporting documentation with the request.

Granting of prior authorization does not guarantee payment for the item/service.

Upon completion of the review, the member and requesting provider are notified. The provider receives an authorization number that must be included on the claim. If the requesting provider does not receive the authorization number within 10 business days of being notified of the review approval, the requesting provider may call Mountain-Pacific Quality Health (MPQH) at (877) 443-4021.

For the prior authorization criteria for DME, see below or on the Prior Authorization Information link in the left menu on the Provider Information website.

Prior Authorization Information

Durable Medical Equipment (DME) Prior Auth Contact:

MPQH
(406) 457-3060 Helena
(877) 443-4021 Long-distance

Documentation Requirements:

Medical necessity documentation must include all of the following:

• Completed DMEPOS Prior Authorization Request  through the Qualitrac Portal.
• Supporting documentation, which must include at a minimum:
  • Prescription
  • Certificate of medical need (if required for the item)
  • Narrative summary from the prescribing authority detailing the need for the item
  • A manufacturers retail price sheet and product warranty information

For members being treated by a licensed therapist, a copy of the member’s plan of care in relation to the item/service is required; video if possible.

End of Prior Authorization Chapter

Covered Services

General Coverage Principles

This chapter provides covered services information that applies specifically to services and supplies provided by Durable Medical Equipment, Prosthetic, Orthotic and Medical Supply (DMEPOS) providers. Like all healthcare services received by Montana Healthcare Programs members, services rendered by these providers must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers Manual.

Montana Healthcare Programs follows Medicare’s coverage requirements for most items. A Medicare manual is available from the Durable Medical Equipment Regional Carriers (DMERC) website, https://med.noridianmedicare.com/web/jddme. Montana Healthcare Programs considers Medicare Region D DMERC medical review policies as the minimum DMEPOS industry standard. This manual covers criteria for certain items/services which are either in addition to Medicare requirements or are services Medicare does not cover.

Montana Healthcare Programs coverage determinations are a combination of Medicare Region D DMERC policies, Centers for Medicare and Medicaid Services (CMS), national coverage decisions (NCDs), local coverage determinations (LCDs), and Department designated medical review decisions. DMEPOS providers are required to follow specific Montana Healthcare Programs policy or applicable Medicare policy when Montana Healthcare Programs policy does not exist. When Medicare makes a determination of medical necessity, that determination is applicable to the Montana Healthcare Programs.

Provision of Services (ARM 37.86.1802)

Federal regulations require that items/services covered by the Department are reasonable and necessary in amount, duration, and scope to achieve their purpose. DMEPOS items/supplies must be medically necessary, prescribed in writing, and delivered in the most appropriate and cost-effective manner, and may not be excluded by any other state or federal rules or regulations.

Supplier Documentation (ARM 37.86.1802)

All covered DMEPOS items for members with Montana Healthcare Programs as the primary payer, must be prescribed by a physician or other licensed practitioner of the healing arts within the scope of the provider’s practice as defined by state law. A prescription or order must include the member's name or Medicaid identification number; order date; general description of the item or HCPCS code or HCPCS code narrative, or a brand name and model number; quantity to be dispensed, if applicable; treating practitioner's name or national provider identifier; and treating practitioner's signature. Prescriptions for oxygen must also include the liter flow per minute, hours of use per day and the member’s PO2 or oxygen saturation blood test results. If applicable, an order for durable medical equipment must list separately all concurrently ordered options, accessories, or additional features that are separately billed or require an upgrade code. If applicable, an order for medical supplies must include all concurrently ordered supplies that are separately billed, listing each separately.

DMEPOS suppliers must obtain a written prescription in accordance with ARM 37.86.1802. Suppliers should also maintain documentation showing the member meets the Medicare coverage criteria.

ARM 37.86.1802 describes how prescriptions/orders can be transmitted. The rule refers providers to the Medicare guidelines. Prescriptions can be oral, faxed, or hard copy. For items that are dispensed based on a verbal order, the supplier must obtain a written order that meets the requirements in Chapter 3 of the Medicare Supplier Manual. The rule refers to current Medicare rules and regulations in the Region D Medicare Supplier Manual (including the most current LCDs). Chapters 3 and 4 of the Medicare Suppliers Manual outline the documentation requirements for suppliers.

Although a prescription is required, coverage decisions are not based solely on the prescription. Coverage decisions are based on objective, supporting information about the member’s condition in relation to the item/service prescribed. Supporting documentation may include but is not limited to (if applicable) a Certificate of Medical Necessity (CMN), DME Information Form (DIF), and/or a physician’s, therapist’s or specialist’s written opinion/attestation for an item/service based on unique individual need.

The member’s medical record must contain sufficient documentation of the member's medical condition to substantiate the necessity for the prescribed item/service. The member’s medical record is not limited to the physician’s office records. It may include hospital, nursing home, or home health agency records and records from other professionals including, but not limited to, nurses, physical and occupational therapists, prosthetists, and orthotists. It is recommended that suppliers obtain (for their files) sufficient medical records to determine whether the member meets Montana Healthcare Programs coverage and payment rules for the particular item.

Proof of delivery is required in order to verify that the member received the DMEPOS item. Proof of delivery documentation must be made available to the Department upon request. Montana Healthcare Programs does not pay for delivery, mailing or shipping fees or other costs of transporting the item to the member’s residence.

The effective date of an order/script is the date in which it was signed.

Providers must retain the original prescription, supporting medical need documentation and proof of delivery. For additional documentation requirements, see the General Information for Providers Manual, Provider Requirements chapter, and Chapters 3 and 4 of the Medicare Supplier Manual.

Certificate of Medical Necessity

For a number of DMEPOS items, a certificate of medical necessity (CMN) is required to provide supporting documentation for the member’s medical indications. Montana Healthcare Programs adopts the CMNs used by Medicare DMERCs, approved by the Office of Management and Budget (OMB), and required by CMS.

These forms are available on the websites listed below:

• Provider Information website, https://medicaidprovider.mt.gov/forms
• CMS website, http://www.cms.gov
• Noridian website, https://med.noridianmedicare.com/web/jddme

The following is a list of items that require a CMN and the corresponding form. This reference list will be updated as changes are made. If any discrepancies exist between these referenced forms and what is published by CMS and Medicare, the CMS and Medicare policy shall take precedence. See Chapter 4 of the Medicare Supplier Manual.

Certificate of Medical Necessity (CMN) Forms

Item:  Lymphedema Pumps (Pneumatic Compression Devices)
Form:  CMS-846   Form Date:  06/2019

Item:  Osteogenesis Stimulators
Form:  CMS-847   Form Date:  06/2019

Item:  Oxygen
Form:  CMS-484  Form Date:  12/2018

Item:  Seat Lift Mechanisms
Form:  CMS-849  Form Date:  06/2019

Item:  Section C Continuation Form
Form:  CMS-854  Form Date:  06/2019

Item:  Transcutaneous Electrical Nerve Stimulators (TENS)
Form:  CMS-848  Form Date:  06/2019

DME Information Forms

Item:  External Infusion Pumps
Form:  CMS-10125  Form Date:  06/2019

Item:  Enteral and Parental Nutrition
Form:  CMS-10126  Form Date:  06/2019

Rental/Purchase (ARM 37.86.1801–1806)

The rental period for items identified by Medicare as capped, routine, or inexpensive are limited to 13 months of rental reimbursement. After 13 months of continuous rental, the item is considered owned by the member and the provider must transfer ownership to the member. Total Montana Healthcare Programs rental reimbursement for items listed in Medicare’s capped rental program or classified by Medicare as routine and inexpensive rental are limited to the purchase price for that item listed on the Montana Healthcare Programs fee schedule. If purchasing the rental item is cost effective, the Department may cover the purchase of the item. See Chapter 5 of the Medicare Supplier Manual.

A statement of medical necessity for rental of DME equipment must indicate the length of time the equipment is needed, and all prescriptions must be signed and dated.

Servicing

During the 13-month rental period, Montana Healthcare Programs rental payment includes all supplies, maintenance, repair, components, adjustments, and services related to the item during the rental month. Separately billable supply items identified and allowed by Medicare are also separately billable to Montana Healthcare Programs under the same limitations. No additional amounts related to the item may be billed or reimbursed for the item during the 13-month period. During the rental period, the supplier providing the rental equipment is responsible for all maintenance and service. After the 13-month rental period when ownership of the item is transferred to the member, the provider may bill Montana Healthcare Programs for the supplies, maintenance, repair components, adjustment and services related to the items. Montana Healthcare Programs does not cover repair charges during the manufacturer’s warranty period.

Items classified by Medicare as needing frequent and substantial servicing are covered on a monthly rental basis only. The 13-month rental limit does not apply, and rental payment may continue as long as the item is medically necessary.

Interruptions in rental period

Interruptions in the rental period of less than 60 days will not result in the start of a new 13-month period or new purchase price limit. Periods in which service is interrupted do not count toward the 13-month rental limit.

Change in supplier

A change in supplier during the 13-month rental period will not result in the start of a new 13-month period or new purchase price limit. Providers are responsible for investigating whether another supplier has been providing the item to the member; Montana Healthcare Programs does not notify suppliers of this information. The provider may rely upon a separate written member statement that another supplier has not been providing the item, unless the provider has knowledge of other facts or information indicating that another supplier has been providing the item. The supplier providing the item in the 13th month of the rental period is responsible for transferring ownership to the member.

Change in equipment

If rental equipment is changed to different but similar equipment, the change will result in the start of a new 13-month period or new purchase price limit only when all of the following are met:

• The change in equipment is medically necessary as a result of a substantial change in the member’s medical condition.
• A new certification of medical necessity for the new equipment is completed and signed by a physician.

No more than one month’s medical supplies may be provided to a member at one time.

Coverage of Specific Services

The simplest way to verify coverage for a specific service is to check the Department’s fee schedule for your provider type. Fee schedules are available on the Provider Information website.

In addition to being listed on the fee schedule, all services provided must also meet the coverage criteria listed in the Provider Requirements chapter of the General Information for Providers Manual and in this chapter. Use the fee schedule in conjunction with the detailed coding descriptions in the CPT and HCPCS coding books that pertain to the date of service.

The following are specific criteria for certain items/services which are either in addition to Medicare requirements or are services Medicare does not cover.

Billing of Miscellaneous Code B9998

Supplies listed below that are included in the daily kits but billed with B9998 will be denied. Providers should review supplies being billed with the miscellaneous code and bill according to the following guidelines.

Medicare Coding Guidelines

The codes for enteral feeding supplies (B4034–B4036) include all supplies, other than the feeding tube itself, required for the administration of enteral nutrients to the member for one day.

Codes B4034–B4036 describes a daily supply fee rather than a specifically defined kit. Some items are changed daily; others may be used for multiple days. Items included in these codes are not limited to prepackaged kits bundled by manufacturers or distributors.

These supplies include, but are not limited to, feeding bag/container, flushing solution bag/container, administration set tubing, extension tubing, feeding/flushing syringes, gastrostomy tube holder, dressings (any type) used for gastrostomy tube site, tape (to secure tube or dressings), Y connector, adapter, gastric pressure relief valve, declogging device, etc.

These items must not be separately billed using the miscellaneous code (B9998) or by using specific codes for dressings or tape. The use of member items may differ from member-to-member and from day-to-day.

Blood Glucose Monitors and Related Supplies

For blood glucose monitors and related supplies, the Department will follow the criteria set forth in the LCD for glucose monitors (L33822):

1. The member has diabetes mellitus or gestational diabetes; and
2. The physician has provided the member (or the member’s caregiver) with adequate training for the device prescribed.

Montana Healthcare programs will allow the following for test strips and lancets:

Members who are not insulin dependent are allowed up to 100 test strips and up to 100 lancets every 3 months if the above criteria have been met.

Members who are insulin dependent are allowed up to 300 test strips and up to 300 lancets every 3 months if the above criteria have been met.

High Utilization

For both members who are not insulin dependent or insulin dependent and require more than the allowed number of test strips and lancets every 3 months, high utilization will be covered if the criteria (a)-(c) below have been met. 

1. Basic coverage criteria (1)-(2) listed above are met; and
2. The treating physician has seen the member, evaluated their diabetes control within 6 months prior to ordering quantities of strips and lancets that exceed the utilization guidelines, and has documented in the member's medical record the specific reason for the additional materials for that particular member; and
3. If refills of quantities of supplies that exceed the utilization guidelines are dispensed, there must be documentation in the physician's records (e.g., a specific narrative statement that adequately documents the frequency at which the member is actually testing or a copy of the member’s log) that the member is actually testing at a frequency that corroborates the quantity of supplies that have been dispensed. If the member is regularly using quantities of supplies that exceed the utilization guidelines, new documentation must be present at least every six months.

Providers submitting claims with units considered high utilization must ensure all of the above requirements for high utilization are met. To process claims for high utilization members, the procedure below shall be followed:

• Indicate any associated insulin use in the appropriate field using ICD-10 code Z79.4. If this code is not present, the claim will be denied. 
• If the high utilization claim is for a child age birth through 20, a "1" must be entered in column H (EPSDT) on the CMS-1500 paper claim form or a "Y" must be entered in the SV-111 field within the 837 electronic. claim format. This will enable the claim to bypass the edit for over the usual allowable units without rejection or denying the claim first.

Insulin Pumps E0784

Insulin pumps do not require prior authorization.  DME providers are reminded before providing insulin pumps to covered Montana Healthcare Programs members, the member must meet the Medicare coverage criteria. The coverage criteria are outlined in the External Infusion Pumps local coverage determination (LCD) located on the Noridian website. https://med.noridianmedicare.com/documents/2230703/7218263/External+Infusion+Pumps+LCD+and+PA.

For enrolled members ages 0-20 only, the criteria for insulin pumps and supplies is not subject to Medicare's criteria outlined above. The criteria for this age group is that the member is insulin dependent.

Therapeutic Continuous Glucose Monitor (CGM) Devices and Sensors – K0554 & K0553

Montana Healthcare Programs covers therapeutic continuous glucose monitor (CGM) devices that are classified by CMS as “therapeutic CGMs” for members ages 4 and up without prior authorization. Children under the age of 4 will require prior authorization.

Not all products marketed as CGM devices are considered therapeutic CGMs.

A therapeutic CGM is one that meets the definition of DME and is labeled by the Food & Drug Administration (FDA) for non-adjunctive use (i.e., it can be used to make treatment decisions without the need for a stand-alone home blood glucose monitor (BGM) to confirm testing results).

Therapeutic CGMs and related supplies are covered when all of the following coverage criteria below (1-5) are met:

1. The member has diabetes mellitus; and
2. The member is insulin-treated with multiple (three or more) daily administrations of insulin or a continuous subcutaneous insulin infusion (CSII) pump; and
3. The member’s insulin treatment regimen requires frequent adjustment by the member on the basis of BGM or CGM testing results; and
4. Within six (6) months prior to ordering the CGM, the treating practitioner has an in-person visit with the member to evaluate their diabetes control and determined that criteria (1-3) above are met; and
5. Every six (6) months following the initial prescription of the CGM, the treating practitioner has an in person visit with the member to assess adherence to their CGM regimen and diabetes treatment plan.

When a therapeutic CGM (code K0554) is covered, the related supply allowance (code K0553) is also covered.

A therapeutic CGM system replaces a standard BGM and related supplies. During the time a CGM is being billed with the associated supply allowance, Montana Healthcare Programs will no longer pay separately for the BGM and supplies.

All therapeutic CGM devices billed to Montana Healthcare Programs using HCPCS code K0554 must be listed on the Data Analysis and Coding (PDAC) Product Classification List for HCPCS code K0554.

If any of coverage criteria (1-5) are not met, the CGM and related supply allowance will be denied as not reasonable and necessary.

Supplies for Therapeutic CGM Devices

Montana Healthcare Programs pays a supply allowance for supplies used with a therapeutic CGM system. For K0553, one (1 unit) supply allowance is payable per 30 days and encompasses all items necessary for the use of the device. Items deemed necessary for use of the device include, but are not limited to, CGM sensor, CGM transmitter, home BGM and related BGM supplies (test strips, lancets, lancing device, calibration solutions) and batteries. Sufficient supplies must be provided to the member to last at least 30 days of therapy. K0553 must not be used for supplies used with CGM coded as A9278.

• Only one (1) UOS of code K0553 may be billed to the DME MACs at a time.
• Billing more than one (1) UOS per 30 days for code K0553 will be denied as not reasonable and necessary.

Non-Therapeutic CGM Devices, Codes A9278, A9277, and A9276

Code A9278 (Receiver (monitor); external, for use with interstitial continuous glucose monitoring system) describes any CGM system that fails to meet the DME Benefit requirements as described in CMS Ruling 1682R. A device that requires the additional use of a stand-alone home BGM to make treatment decisions to confirm testing results.

Products not listed on the Data Analysis and Coding (PDAC) Product Classification List for HCPCS code K0554 do not meet the requirements for a therapeutic CGM and must be coded as A9278.

Code A9276 (Sensor; invasive (e.g., subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1 day supply) and code A9277 (Transmitter; external, for use with interstitial continuous glucose monitoring system) describe the supplies used with a non-therapeutic CGM. Codes A9276 and A9277 are not used to bill for supplies used with code K0554.

Non-Therapeutic CGM Criteria

Non-therapeutic CGMs and related supplies require prior authorization and will be covered by Montana Healthcare Programs under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit for eligible Montana Healthcare Programs members if the following coverage criteria below (1-4) are met:

1. Member is under the age of 21; and
2. Member has a diagnosis of insulin dependent diabetes mellitus; and
3. Clinically documented compliance with diabetes management plan, with current clinical notes dated within 90 days; and
4. Patient and/or parent education provided on proper use of the device.

Submit prior authorization requests to Mountain-Pacific Quality Health through the Qualitrac Web Portal. Providers will need to select EPSDT when submitting PA requests.

For continuation of supplies the following criteria must be met:

1. Clinically documented compliance with diabetes management plan.
2. Continued use of the CGM.

Please note:
Montana Healthcare Programs allows 30 units per month for items coded as A9276 and 1 unit every 6 months for items coded as A9277.

• All clinical documentation must be dated within 90 days of the member receiving the device or supplies.
• Members 3 years of age and under who meet the above criteria will be reviewed by MPQH on a case-by-case basis.

Breast Pumps

Double Electric Breast Pumps for Purchase E0603

Double electric breast pumps are covered for all eligible Montana Healthcare Programs members who are at least 28 weeks gestation, or currently breastfeeding. Montana Healthcare Programs has a sole source provider, Healthy Babies, Happy Moms. 

The ordering process is a two-part process.

1. Member must go online and order their breast pump online at Montana Medicaid Breast Pumps — Healthy Babies, Happy Moms Inc.
2. Providers must send prescriptions to Healthy Babies, Happy Moms Inc. via fax to (844) 276-5457. The prescription template is available on the Healthy Babies, Happy Moms website.

Providers are reminded that prescriptions must include the following: 

• Member name 
• Member ID 
• Date of birth 
• Order date 
• Printed name and signature of authorized provider 
• Valid diagnosis code for a pregnant member or for a nursing member 
• Estimated due date or gestational age 
• Medical necessity 
• Projected length of need 
• Member's mailing address 
• Member's phone number 

All orders will be delivered within 5 business days from the receipt of a fully completed order, which includes prescription from authorized provider and patient's online order. Pumps can only be provided to a member who is at least 28 weeks pregnant or is breastfeeding. 

Please note: 

• Only one breast pump will be provided per pregnancy and no more than one breast pump will be provided per year. 

For more information regarding Healthy Babies, Happy Moms Inc. and information regarding breast pumps available through Medicaid please see the following website: https://www.MontanaMedicaidBreastpumps.com.

Hospital Grade Electric Breast Pump Rentals E0604 RR:

Hospital grade electric breast pump rentals are a covered service if at least one of the following criteria has been met:

• Member has a preterm infant of 39 weeks or less gestation
• Infant has feeding difficulties due to a neurological or physical condition that impairs adequate suckling
• Illness of member and/or infant that results in their separation
• Member is on a mediation that compromises her milk supply; or
• Member has multiple infants.

Hospital grade electric breast pump rental is limited for 2 months, unless additional months are prior authorized by Mountain-Pacific Quality Health through the Qualitrac portal. https://www.mpqhf.org/corporate/medicaid-portal-home/medicaid-portal-document-library/. Montana Healthcare Programs payment may not be provided through the infant’s eligibility.

Combination Shower Commode Chairs and Accessories, Screening Criteria

Use HCPCS Code E0240 when submitting prior authorization request and/or when billing for the shower commode chair. This code does require prior authorization and must meet the criteria listed below:

Description

A combination shower commode chair is used to meet a member's toileting and hygiene needs.

Indications for coverage of the shower commode chair

All of the following criteria must be met:

• Unable to use a standard conventional toilet.
• Unable to get in/out of the shower independently and is unable to sit or stand in the bath/shower independently.
• Home assessment determines that shower/tub access is possible for the requested equipment.
• Home assessment determines that once the equipment is in the shower/tub enclosure caregiver access to the member is adequate.
• Documentation to support that a less costly system will not meet the needs of the member.

Indications for coverage of the tilt/recline feature

Documentation to support the medically necessity for the member to be in a tilt/recline position for toileting or showering.

Indications for coverage of a non-standard seating system

• Current decubitus that is a stage 3 or 4; and
• Shower/commode chair needed for a minimum of 30 minutes or longer; or
• No decubitus and use of the shower/commode chair for a minimum of 2 hours or longer per toileting session.

Indications for coverage of foot plates

No functional use of the lower limbs.

Indications for coverage of elevating leg rests

Musculoskeletal condition which prevents 90-degree flexion of the knee or meets medical necessity for the tilt/recline feature on the shower/commode chair.

Indications for coverage of a heavy-duty shower/commode chair

Documentation from a medical resource of the member's weight to determine justification for the requested chair.

Compression Garments for the Legs

Inflatable compression garments, non-elastic binders, or personally fitted prescription gradient compression stockings are considered medically necessary for members who have any of the following medical conditions:

• Treatment of any of the following complications of chronic venous insufficiency:
  • Lipodermatosclerosis
  • Stasis dermatitis (venous eczema)
  • Varicose veins (except spider veins)
  • Venous edema
  • Venous ulcers (stasis ulcers)
• Edema accompanying paraplegia, quadriplegia
• Edema following surgery, fracture, burns, or other trauma
• Members with lymphedema
• Post sclerotherapy (applies only to pre-made or custom-made pressure gradient support stockings)
• Post-thrombotic syndrome (post-phlebetic syndrome)
• Postural hypotension
• Prevention of thrombosis in immobilized members (e.g., immobilization due to surgery, trauma, general debilitation)
• Severe edema in pregnancy

Compression garments for the legs are considered experimental and investigational for all other indications (e.g., management of spasticity following stroke) and will not be covered.

Replacements

Are considered medically necessary when the compression garment cannot be repaired or when required due to a change in the member’s physical condition. For pressure gradient support stockings, no more than 4 replacements per year are considered medically necessary for wear.

Two pairs of compression stockings are considered medically necessary in the initial purchase. The second pair is for use while the first pair is in the laundry. For a list of covered compression stocking codes, see the fee schedule on the Provider Information website.

Custom-Made Equipment, Prosthetics, or Orthotics

DME must be billed using the date of service the member receives the equipment or item.

The only exception is in the case of custom-made equipment, prosthetics, or orthotics. In these instances, the date when the item is casted, molded, and/or fitted may be used. Before a provider can bill for any custom-made equipment, prosthetic or orthotic, the work on the item must be complete and the member must have signed the delivery ticket.

Because Montana Healthcare Programs eligibility is determined on a month-to-month basis, providers must check eligibility before an item is ordered or work has begun and document the member’s eligibility in their file.

Only one unit of service may be billed for any one day. Units of service in excess of one per day will be rejected as incorrect coding. 

Gastrostomy/Jejunostomy Tube, Code B4088

This code has been incorrectly profiled in the HCPCS coding book. The code is described as just a tube, when in fact it is a complete kit. The manufacturer will not supply the tube separate from the kit. Medicare currently reimburses code B4088 as a tube, but suppliers are billed by the manufacturer for the complete kit. Therefore, the reimbursement to the suppliers is not adequate in comparison to the cost for the complete kit.

Montana Healthcare Programs recognizes the constraints this has put on suppliers when providing this item to members. Effective immediately, Montana Healthcare Programs will reimburse code B4088 at 75% of the Manufacturer’s Suggested Retail Price (MSRP) in accordance with ARM 37.86.1807.

Incontinence Supplies

Diapers, Underpads, Liners/Shields

• Diapers, underpads, and liners/shields are covered for members who have a medical need for the items based on their diagnosis.
• These items are not covered for members under 3 years of age or members in long-term care (nursing facility) settings.
• Montana Healthcare Programs limits the number of incontinent products distributed by product type:
  
  • Disposable diapers are limited to 180 diapers per month.
  • Disposable under pads liners/shields are limited to 240 per month.
  • Reusable diapers, under pads, liner/shields are limited to 36 units each per year (3 per month).

Sterile and Non-Sterile Gloves

Both sterile and non-sterile gloves are considered incontinence supplies only.

• Gloves are covered for members who have a medical need for the items based on their diagnosis (i.e., diagnosis is incontinence).
• Sterile gloves (A4930) are billed per pair.
• Non-sterile gloves (A4927) are billed per box.
• Gloves are reimbursed at 75% of the Manufacturers Suggested Retail Price (MSRP).
• For gloves without MSRP, providers may submit their Usual and Customary (U&C) charge as long as it does not exceed 50% of their acquisition cost.

The T codes listed below are more specific to the type of incontinence products being distributed by Montana Healthcare Programs DME providers:

Incontinence Products HCPCS Codes

Code: T4521   Description:  Adult sized disposable incontinence product, brief/diaper, small, each

Code: T4522   Description:  Adult sized disposable incontinence product, brief/diaper, medium, each

Code: T4523   Description:  Adult sized disposable incontinence product, brief/diaper, large, each

Code: T4524   Description:  Adult sized disposable incontinence product, brief/diaper, extra-large, each

Code: T4525   Description:  Adult sized disposable incontinence product, protective underwear/pull-on, small, each

Code: T4526   Description:  Adult sized disposable incontinence product, protective underwear/pull-on, medium, each

Code: T4527   Description:  Adult sized disposable incontinence product, protective underwear/pull-on, large, each

Code: T4528   Description:  Adult sized disposable incontinence product, protective underwear/pull-on, extra-large, each

Code: T4529   Description:  Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each

Code: T4530   Description:  Pediatric sized disposable incontinence product, brief/diaper, large size, each

Code: T4531   Description:  Pediatric sized disposable incontinence product, protective underwear/pull-on, small/medium size, each

Code: T4532   Description:  Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each

Code: T4533   Description:  Youth sized disposable incontinence product, brief/diaper, each

Code: T4534   Description:  Youth sized disposable incontinence product, protective underwear/pull-on, each

Code: T4535   Description:  Disposable liner/shield/guard/pad/ undergarment, for incontinence, each

Code: T4536   Description:  Incontinence product, protective underwear/pull-on, reusable, any size, each

Code: T4537   Description:  Incontinence product, protective underpad, reusable, bed size, each

Code: T4539   Description:  Incontinence product, diaper/brief, reusable, any size, each

Code: T4540   Description:  Incontinence product, protective underpad, reusable, chair size, each

Code: T4541   Description:  Incontinence product, disposable underpad, large, each

Code: T4542   Description:  Incontinence product, disposable underpad, small size, each

Code: T4543   Description:  Disposable incontinence product, brief/diaper, bariatric, each

Prosthetic Devices

HCPCS codes L5000-L7520, L8040-L8515, and L8630-L8670 no longer require prior authorization.

In accordance with Administrative Rules of Montana (ARM) 37.86.1802, Montana Medicaid has adopted Medicare coverage criteria for Medicare covered durable medical equipment as outlined in the Region D Supplier Manual, local coverage determinations (LCDs) and national coverage determinations (NCDs).

Providers are reminded that members must meet the Medicare coverage criteria. The criteria can be found at the following documentation checklists and at the following Noridian website: https://med.noridianmedicare.com/web/jddme/policies/lcd/active.
 
Lower Limb Prostheses - LCD 33787 Documentation Checklist: https://med.noridianmedicare.com/documents/2230703/6750839/Documentation+Checklist+-+Lower+Limb+Prostheses

Facial Prostheses - LCD 33738
 
Eye Prostheses - LCD 33737
 
External Breast Prostheses  - LCD 33317   Documentation Checklist: https://med.noridianmedicare.com/documents/2230703/6750839/Documentation+Checklist+-+External+Breast+Prostheses
 
Upper Extremity Prostheses - Criteria can be found in Section 120 of the Medicare Benefit Policy Manual, Chapter 15: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf.

Respiratory Devices

Apnea Monitors - Infants 

See the Respiratory Devices section under Children’s (EPSDT) Coverage Criteria for Specified DME  of this chapter below.

Bi-level Positive Airway Pressure Devices (Bi-Pap) E0470 – E0471

Bi-level positive airway pressure device with back-up rate, does not require prior authorization.  Providers are reminded of the following Medicare LCD L33718 medically necessary criteria that must be met in order for Medicaid reimbursement to include: 

E0470 Obstructive Sleep Apnea: 

A. The member must have a face-to-face clinical evaluation by the treating practitioner prior to the sleep test to assess the member for obstructive sleep apnea. 
B. The member must have a sleep test (as defined below) that meets either of the following criteria (1 or 2): 

1. The Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events;
   OR 
2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
   1. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or
   2. Hypertension, ischemic heart disease, or history of stroke. 

C. The member and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.  
D. A single-level continuous positive airway pressure device (E0601) has been tried and proven ineffective based on a therapeutic trial conducted in ether a facility or in a home setting.

E0470 and E0471 Respiratory Assist Devices (RAD): 

For an E0470 or an E0471 RAD to be covered, the treating physician must fully document in the member's medical record symptoms characteristic of sleep-associated hypoventilation, such as daytime hypersomnolence, excessive fatigue, morning headache, cognitive dysfunction, dyspnea, etc.

A RAD (E0470 or E0471) is covered for those beneficiaries with one of the following clinical disorders:  

• Restrictive thoracic disorders (i.e., neuromuscular diseases or severe thoracic cage abnormalities)
• Severe chronic obstructive pulmonary disease (COPD)
• CSA or CompSA
• Hypoventilation syndrome

Items coded as E0470 and E0471 do not require prior authorization if the coverage criteria are met.

Home Oxygen Therapy for Members Residing in Skilled Nursing Facility

In accordance with ARM 37.86.1802, Montana Healthcare Programs has adopted Medicare coverage criteria for Medicare covered durable medical equipment as outlined in the Region D Supplier Manual, Medicare Supplier Manual, and local and national coverage determinations (LCDs and NCDs).

For prosthetic devices, durable medical equipment, and medical supplies not covered by Medicare, coverage will be determined by the Department and published on the Department’s fee schedule in accordance with ARM 37.86.1807.

The Department will follow criteria set forth in the LCD for Oxygen and Oxygen Equipment (L11457) for members residing in a skilled nursing facility. The only exception is that the Department will allow oximetry tests ordered by a physician and performed by qualified nursing personnel at the skilled nursing facility as an acceptable blood gas study. To be reimbursed for this service, DME providers shall follow all other criteria set forth in L11457.

Montana Healthcare Programs Policy on 36-Month Oxygen Cap

To preserve member access, Montana Healthcare Programs will not be following the Medicare 36-month cap policy on oxygen for Montana Healthcare Programs-only members. This policy will include eligible Montana Healthcare Programs nursing home dual-eligible (both Medicare and Montana Healthcare Programs coverage) members for Medicare non-covered oxygen. Montana Healthcare Programs pays only Medicare co-insurance and deductibles up to the Montana Healthcare Programs allowable for QMB-only members. The Department will follow established policy for this member group. For example, once the 36-month cap starts, Medicare rules apply, and the Department will follow.

Dual-eligible members will follow the 36-month cap as outlined by Medicare rules. Montana Healthcare Programs members with QMB and SLMB do not have Montana Healthcare Programs oxygen coverage. Montana Healthcare Programs will follow all of the Medicare oxygen changes outlined in the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 except for the 36-month cap as stated above.

Home Ventilators E0465, E0466, and E0467

The following documentation requirements apply for both invasive and non-invasive home ventilators and should be submitted with each prior authorization request.

Requirements for initial home ventilator requests:

• Ordering Health Care Provider/Prescriber (HCP) notes detailing the diagnosis for which the ventilator is required. This is to include diagnoses such as progressive neuromuscular disease, thoracic restrictive conditions, cardiac conditions, COPD, upper airway conditions, and other causes of respiratory failure.
• The HCP’s notes must document why less costly alternatives such as simple oxygen therapy, maximal medical management, bilevel and/or other respiratory assistive devices, etc., are not suitable. This might be because they were tried and failed, they are inappropriate for the patient's condition with an explanation as to why, or some other specific reason why less costly alternatives will not meet the patient’s needs.
• The notes must include objective data such as blood gas measurements, Pulmonary Function Test (PFT), oximetry, sleep study interpretations, and any other laboratory and diagnostic imaging that supports the need for home ventilation. This does not mean that absolute lab or test values will be used for authorization. It means that the ordering HCP’s judgment, informed by the objective data will be the ultimate determinant of need.
• The original prescription from the ordering HCP.
• A Detailed Written Order (DWO)* must also be provided: This includes:
  
  • Estimated length of need – this may be undetermined but might also vary in the case of convalescence from an exacerbation of a condition
  • Hours of use
  • Ventilator settings

*A prescription alone that does not include this information will not be sufficient.

After initial approval:

Prescribers shall determine the frequency of follow-up assessments. Providers must document all updated orders and/or information regarding treatment in the medical record. Providers are reminded, in accordance with 42 CFR 440.70, the need for medical supplies, equipment, and appliances should be identified by the prescriber and reviewed at least annually. Face-to-face assessments of the patient by the prescriber can be performed using telemedicine. Telemedicine guidance can be found in the General Information for Providers Manual.

To renew a prior authorization:

• A recent order by the treating physician/practitioner for refills; or
• A recent change in prescription; or
• Timely documentation in the member's medical record showing usage of the item.

• Timely documentation in the member’s medical record showing usage of the item.
• Supplier records such as compliance logs or service plans.
• Supplier records documenting member confirmation of continued use.

Ventilators are not subject to the 13-month rental period. Ventilators are reimbursed as a rental only.

Wheelchairs

In addition to the Medicare Region D DMERC Medical Review Policies for wheelchairs, to meet the needs of a particular member, various wheelchair options or accessories are typically selected. The addition of options or accessories does not deem the wheelchair as a custom wheelchair.

Wheelchairs in Nursing Facilities

Nursing facilities are expected to make available wheelchairs with typical options or accessories in a range of sizes to meet the needs of its members. If a typical option or accessory is not available for a currently owned nursing facility wheelchair, an accommodating wheelchair is expected to be made available by the nursing facility. Only wheelchairs (including power chairs) that cannot be reasonably used by another nursing home member will be considered for purchase. Wheelchairs must be used primarily for mobility. Roll-about chairs which cannot be self-propelled are specifically designed to meet the needs of ill, injured, or otherwise impaired members and are considered similar to wheelchairs. Roll-about chairs may be called by other names such as transport or mobile geriatric chairs (geri chairs). Roll-about chairs are not wheelchairs; however, many of the same options and accessories can be found for use on them. Like standard wheelchairs, roll-about chairs are expected to be available to Members by the nursing facility.

Wheelchair Seating in the Nursing Facility

Indications and limitations for a wheelchair seating system for an existing wheelchair such as a facility wheelchair, member owned wheelchair or a donated wheelchair. The seating system would be the least costly alternative that is able to be adapted to meet the positioning needs of a member in a nursing home and will be covered if there is a comprehensive written evaluation by a licensed clinician who is not an employee of or otherwise paid by a supplier.

Included in the evaluation referenced above are the following:

• Seating systems for increased independence
• Documentation must support all of the following:
  • The member must be able to self-propel to specific destinations (e.g., to and from the dining room, to and from the activity room).
  • Be able to do a functionally independent task as a result of the seating system such as feed self.
  • The member must be evaluated to determine that he/she is able to safely self-propel and does not have the potential cause harm.
• Be alert and oriented and capable of being completely independent in use of the wheelchair after adapted seating system is placed.

OR

• Seating systems for positioning purposes
• Seating for positioning purposes will be reviewed on a case-by-case basis.
• Documentation must support that all other less costly alternatives have been ruled out, to include but not be limited to use of the following:
  • Use of mobile geriatric chairs (geri chairs) provided by nursing home and use of standard off-the-shelf seating products have been tried and ruled out; and
  • Use of rolled towels, blankets, pillows, wedges, or similar devices by facility caregivers to reasonably position and reposition member; and
  • Documentation that has determined that nursing staff is unable to accomplish repositioning by any other means while the member is up and out of bed; and member is not incapacitated to the point that he/she is bedridden.

Children’s (EPSDT) Coverage Criteria for Specified DME

ARM 37.86.2201 allows for coverage of a durable medical equipment (DME) item/service that is typically considered non-covered, does not meet coverage criteria, or is over the Montana Healthcare Programs allowable units if the item/service is determined medically necessary for an eligible child under 21.

Bowel Management Program Supplies for EPSDT Children Ages 0-20

For the Enema Bowel Program, the child must:
Have failed a trial of oral medications for chronic constipation AND has ONE or more of the following:

• History of excessive stool retention
• History of painful or hard bowel movements
• Presence of a large fecal mass in the rectum

Supplies covered:

• Foley catheters with 30cc balloon
• Medline enema bags/gravity bags
• Lubricant, non-sterile
• 30-60cc luer lock syringes

For the Appendicostomy/Cecostomy Supplies, the child must:
Have had an appendicostomy/cecostomy.

Supplies covered:

• Chait trapdoor
• Chait access adapter tube
• Enema bags/gravity bags
• 60cc catheter tip syringes

Gait Trainers - EPSDT Only 

A gait trainer (GT) is a device used to support a member during ambulation. Criteria for coverage of GT include:

• The member's age is 0-20.
• The member is unable to ambulate independently with a standard front or reverse walker because of the need for postural support, due to a chronic neurological condition including abnormal movement patterns, poor balance, poor endurance, or other clearly documented reasons.
• The anticipated functional benefits of walking are not attainable with the use of a walker.
• Must demonstrate tolerance for standing and weight bearing through the lower extremities.
• Potential benefits to the member of assisted walking must be clearly documented as follows:
• The member must be involved in a therapy program established by a physical therapist. The program must include measurable documented objectives and functional goals related to the member and equipment that includes a written carry over plan to be utilized by the member and/or caregiver. The equipment must match the user’s needs and ability level.
• The member has had a trial of the requested GT and the member shows compliance, willingness, and ability to use the GT in the home.
• Video of member using the requested GT home demonstrating ability to use GT by showing potential for progress to meet goals and objectives.

Ketone Test Strips, Codes A4250 and A4252

The following HCPCS codes will be covered for Montana Healthcare Programs children ages 0-20 only, who are at immediate risk for diabetic ketoacidosis:

• A4250, Urine test or reagent strips or tablets (100 tablets or strips)
• A4252, Blood ketone test or reagent strip, each

The member must have a diabetes mellitus or gestational diabetes diagnosis code.

MDI Spacers (EPSDT), Code A4627

A spacer device will be allowed for a child if he/she is using metered dose inhalers prescribed by his/her physician for medication delivery, and the spacer is medically necessary.

If the above criteria are met, the item does not require prior authorization. Montana Healthcare Programs will reimburse this code at 75% of the Manufacturer’s Suggested Retail Price (MSRP), in accordance with ARM 37.86.1807.

Nebulizers/Nebulizer Kit (EPSDT), Codes E0570 RR and A7005

Nebulizers and supplies should be considered for in-home treatment of children when prescribed by their medical provider and when the child has been diagnosed with acute bronchiolitis or respiratory syncytial virus (RSV).

The nebulizer and supplies should be considered for a rental of prescribed length of need as indicated by the provider; typically, 1–3 months.

If the above criteria are met, the item does not require prior authorization.

Phototherapy (Bilirubin) Light with Photometer, Code E0202 RR

The E0202 RR will be reimbursed for infants ages 0-1. One unit of service is billed for each day and units billed are not to exceed a 5-day limit. To assure correct coding, providers are encouraged to refer to the current HCPCS coding manual. DMEPOS suppliers must obtain a written prescription in accordance with ARM 37.86.1802. Suppliers should also maintain supporting documentation showing the member meets the Montana Healthcare Programs coverage criteria. 

Orthotics (EPSDT), Codes L3002, L3010, L3020, and L3040

Devices and instruments to help a child maintain his/her level of mobility, correct physical issues, or decrease pain should be considered when prescribed by their medical provider and the following conditions apply. This list is not all-inclusive, and each case is determined on a case-by-case review of medical necessity:

• Knee or hip subluxation, dislocation
• Spastic movement
• Correct, limit or prevent deformities
• Low-tone pronation (fallen arches, outward-turned foot due to muscle weakness)
• High-tone pronation (high arch, outward-turned foot due to increased muscle tone)
• Swing-phase inconsistency (erratic movements in the foot)
• Drop-foot (drop of the front of the foot due to weakness)
• Eversion (outward turn)
• Inversion (inward turn)

If the child is not having symptoms or pain associated with the above conditions, foot orthotics are not considered medically necessary.

If the above criteria are met, the item does not require prior authorization.

Respiratory Devices for Children (EPSDT)

Apnea Monitors - Infants

The rental of an apnea monitor will be covered initially for a six-month period from the date of the physician’s order. Apnea monitors are covered under at least one of the following conditions:

• A sibling has died from SIDS.
• Infant has symptomatic apnea.
• Observation of apparent life-threatening events (ALTE).
• Infant is on oxygen.
• Symptomatic apnea due to neurological impairment.

For coverage after the initial six-month period, additional months coverage must be prior authorized by the Department and the following conditions must exist and be documented by the physician:

• Infant continues to have significant alarms. (Log must be kept on file.)
• Unresolved symptomatic apnea.

Pulse Oximetry for Children Age 0-20

The capped rental of a Pulse Oximetry Meter (E0445) will no longer require prior authorization for children age 0-20 when all of the following criteria are met:

• The member has a chronic, progressive respiratory or cardiovascular condition that requires continuous or frequent oxygen therapy.
• Oxygen need varies from day to day or per activity (e.g., feeding, sleeping, movement), and a medical need exists to maintain oxygen saturation within a very narrow range in which unpredictable, sub therapeutic fluctuations of oxygen saturation levels occur that cannot be clinically determined and have an adverse effect if not treated.
• A trained caregiver is available to respond to changes in oxygen saturation.
• Montana Healthcare Programs will only reimburse for a capped rental if the above criteria are met. Therefore, the purchase of a pulse oximeter will not be approved for reimbursement.  

Continuous read oximetry meters and any meter used for diagnostic purposes are not covered.

Pulse Oximeter Probes (EPSDT), Code A4606

If a child has a pulse oximeter that was paid for by Montana Healthcare Programs, a replacement probe (A4606) will be covered if the pulse oximeter is still medically necessary and prescribed by their medical provider.

If above criteria are met, the item does not require prior authorization. Montana Healthcare Programs will reimburse this code at 75% of the Manufacturer’s Suggested Retail Price (MSRP), in accordance with ARM 37.86.1807.

Oral Nutrition

Montana Healthcare Programs may cover oral nutritional products for members under the age of 21 who have had an EPSDT screen resulting in a diagnosed medical condition that impairs absorption of a specific nutrient. The member must also have a measurable nutrition plan developed by a nutritionist and the member’s primary care provider (PCP). Use modifier -BO when nutrition is orally administered, not by a feeding tube (only for members under age 21).

Oral Food Thickener (EPSDT), Code B4100

The addition of a thickening agent should be considered medically necessary when prescribed by his/her medical provider and the following diagnosis applies:

• Oropharyngeal dysphagia;
• Reflux disease; or
• Any diagnosis that indicates child is at risk for life threatening aspiration.

If the criteria are met, the item does not require prior authorization. Montana Healthcare Programs will reimburse this code at 75% of the Manufacturer’s Suggested Retail Price (MSRP), in accordance with ARM 37.86.1807.

Cranial Remolding Orthotics/Helmets (EPSDT), Code S1040

Prior authorization is not required for cranial remolding orthotics if the following criteria has been met:

For Members 0-6 Months Old

1. Documented moderate to severe deformational or positional plagiocephaly by physical examination or imaging.
2. Continued deformity after at least two months of parent or caregiver education and at least two months of physical therapy or occupational therapy.

For Members 6-18 Months Old

1. Documented moderate to severe deformational or positional plagiocephaly by physical examination or imaging.

If a member has had craniosynostosis surgery, then S1040 is approved for all age groups without the trial conservative therapies.

End of Covered Services Chapter

Non-Covered Services (ARM 37.86.1802)

Below are items and/or categories of items that are not covered through the DMEPOS program. All coverage decisions are based on federal and state mandates for program funding by CMS, including the Medicare program or the Department’s designated review organization.

• Adaptive items for daily living
• Environmental control items
• Building modifications
• Automobile modifications
• Convenience/comfort items
• Disposable incontinence wipes
• Sexual aids or devices
• Member personal care items
• Member personal computers
• Alarms/alert items
• Institutional items
• Exercise/therapeutic items
• Educational items
• Items/services provided to a member in a nursing facility setting. (See the Nursing Facility and Swing Bed Services Manual for details.)
• Furniture associated with the use of a seat lift mechanism.
• Scales
• Backup equipment
• Items included in the nursing home per diem

Requesting an Item/Code Be Added to the Fee Schedule

DME providers and suppliers can request that the Department consider adding non-covered supplies and equipment to the DME plan of benefits or to modify existing coverage criteria. The procedure must allow the Department to make a well-informed decision in regard to considering coverage based primarily on medical necessity. The policy is not a guarantee of coverage.

Requester/Supplier Responsibility

Requester must submit a written request to the DPHHS DME program officer. The request must include the following:

• HCPCS code and a detailed description of the item.
• Clear and concise statement of why the item is needed. This could include a letter of medical necessity (LMN) if available.
• Supporting information documenting the medical necessity for the requested item from peer reviewed national compendia or publication. Evidence must support the need for this equipment to meet the intended medical need.
• A statement addressing if there is a least costly alternative and why it cannot be used.
• Recommended coverage criteria of the requested item.
• Recommended limits. This would include any limits that could apply such as lifetime, units per month, age limits, weight.
• Estimated (per unit) cost of the requested item.
• Estimated number of people that would utilize the item.
• Expected medical outcome.
• Estimated overall cost/cost savings (if any).

The request may include any other pertinent information the requester would like the Department to consider.

Department’s Responsibility and Process

Upon receipt of a request for coverage of a non-covered item, the Department:

• Submits the request and associated documentation to the Department’s DME Utilization Review contractor for evaluation of the request.
• Upon completion of the review, the contractor makes a coverage recommendation to the Department.
• May forward the request to the State Medical Director (SMD) for review.
• If SMD recommends coverage denial, the Department sends letter to the requester explaining why.
• If SMD recommends coverage, the Department determines whether the current budget can fulfill the expense of the item’s expected utilization.
• An adverse budget impact results in a letter to the requester explaining why the item cannot be added.
• Department approval of the request initiates the Administrative Rule and State Plan Amendment process. These are required steps for new items to be added to the DME fee schedule allowing for public comment.
• The Department is responsible for preparing a written response within a reasonable time period to inform all applicable parties of the decision.
• The process could take up to six months. The Department provides quarterly progress reports to the DME workgroup.

End of Non-Covered Services Chapter

Billing Procedures

Using the Montana Healthcare Programs Fee Schedule

When billing Montana Healthcare Programs, it is important to use the Department’s fee schedule for your provider type in conjunction with the detailed coding descriptions listed in the current CPT and HCPCS coding books. In addition to covered services and payment rates, fee schedules often contain helpful information such as appropriate modifiers. Fee schedules are available on the Provider Information website.

Place of Service

Place of service must be entered correctly on each line. Montana Healthcare Programs typically reduces payment for services provided in hospitals and ambulatory surgical centers since these facilities typically bill Montana Healthcare Programs separately for facility charges.

For a list of place of service codes for professional claims, see the link under Coding/Place of Service Codes at http://www.cms.gov/Medicare/Medicare.html.

Date of Service

The date of service for custom molded or fitted items is the date upon which the provider completes the mold or fitting and either orders the equipment from another party or makes an irrevocable commitment to the production of the item.

Rental

Payment includes the entire initial month of rental even if actual days of use are less than the full month. Payment for second or subsequent months is allowed only if the item is used at least 15 days in such months.

End of Billing Procedures Chapter

How Payment Is Calculated

Overview

Although providers do not need the information in this chapter in order to submit claims to Montana Healthcare Programs, the information allows providers to understand how payment is calculated and to predict approximate payment for particular claims.

Usual and Customary Charge (ARM 37.85.406 and ARM 37.86.1806)

Providers should bill Montana Healthcare Programs their usual and customary charge for each service; that is, the same charge that is made to other payers for that service. The amount of the provider’s usual and customary charge may not exceed the reasonable charge usually and customarily charged by the provider to all payers. For DMEPOS providers, a charge is considered reasonable if it is less than or equal to the manufacturer’s suggested list price.

For items without a manufacturer’s suggested list price, the charge is considered reasonable if the provider’s acquisition cost from the manufacturer is at least 50% of the charge amount. For items that are custom fabricated at the place of service, the amount charged will be considered reasonable if it does not exceed the average charge of all Montana Healthcare Programs providers by more than 20%.

Payment for DMEPOS Items/Services (ARM 37.86.1807)

Payment for DMEPOS is equal to the lowest of either the provider’s usual and customary charge for the item or the Montana Healthcare Programs fee schedule amount in effect for the date of service.

Montana Healthcare Programs payment is equal to 100% of Medicare Region D fee schedule for current procedure codes where a Medicare fee is available, less applicable incurment and/or other applicable fees. Generic or miscellaneous procedure codes are excluded from the Medicare fee schedule. Payment for such excluded procedure codes is 75% of the provider’s submitted charge. For all other procedure codes where no Medicare fee is available, payment is 75% of the submitted charge.

Rental Items

If the purchase of a rental item is cost effective in relation to the member’s need of the item, the purchase may be negotiated. The purchase price would be the amount indicated on the applicable fee schedule less previous payments made to the provider of the item.

Total Montana Healthcare Programs rental reimbursement for items listed in Medicare’s capped rental program or classified by Medicare as routine and inexpensive rental is limited to the purchase price for that item. Monthly rental fees are limited to 10% of the purchase for the item, limited to 13 monthly payments. Interruptions in the rental period of less than 60 days do not result in the start of a new 13-month period or new purchase price limit, but periods during which service is interrupted will not count toward the 13-month limit.

How Payment Is Calculated on TPL Claims

When a member has coverage from both Montana Healthcare Programs and another insurance company, the other insurance company is often referred to as third party liability or TPL. In these cases, the other insurance is the primary payer (as described in the Member Eligibility and Responsibilities chapter of the General Information for Providers Manual), and Montana Healthcare Programs makes a payment as the secondary payer.

How Payment is Calculated on Medicare Crossover Claims

When a member has coverage from both Montana Healthcare Programs and Medicare, Medicare is the primary payer as described in the Member Eligibility and Responsibilities chapter of the General Information for Providers Manual. Montana Healthcare Programs then makes a payment as the secondary payer. For the provider types covered in this manual, the Montana Healthcare Programs payment is calculated so that the total payment to the provider is either the Montana Healthcare Programs allowed amount less the Medicare paid amount or the sum of the Medicare coinsurance and deductible, whichever is lower. This method is sometimes called “lower of” pricing.

End of How Payment Is Calculated Chapter

Appendix A: Forms

See the Forms page of the Provider Information website for the forms listed below.

Certificates of Medical Necessity

• Lymphedema Pumps (Pneumatic Compression Devices) (CMS-846)
• Osteogenesis Stimulators (CMS-847)
• Oxygen (CMS-484)
• Seat Lift Mechanisms (CMS-849)
• Section C Continuation Form (CMS-854)
• Transcutaneous Electrical Nerve Stimulators (TENS) (CMS-848)

DME Information Forms

• External Infusion Pumps DME 09.03 (CMS-10125)
• Enteral and Parenteral Nutrition DME 10.03 (CMS-10126)

End of Appendix A: Forms Chapter

End of Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (DMEPOS) Manual