Chapter DHS 107

DHS 107.23(4)(g) (g) SMV transport of an ambulatory recipient, except an ambulatory recipient under sub. (1) (c) 1., to a methadone clinic or physician’s clinic solely to obtain methadone or related services such as drug counseling or urinalysis;

DHS 107.23(4)(h) (h) Transportation by SMV to a pharmacy to have a prescription filled or refilled or to pick up medication or disposable medical supplies;

DHS 107.23(4)(i) (i) Transportation by SMV provided solely to compel a recipient to attend therapy, counseling or any other MA-covered appointment; and

DHS 107.23(4)(j) (j) Transportation to any location where no MA-covered service was provided either at the destination or pick-up point.

DHS 107.23 Note Note: For more information on non-covered services, see s. DHS 107.03.

DHS 107.23 History History: Cr. Register, February, 1986, No. 362, eff. 3-1-86; am. (1) (c) and (4) (5), Register, February, 1988, No. 386, eff. 3-1-88; r. and recr., Register, November, 1994, No. 467, eff. 12-1-94; correction in (3) (a) 4. made under s. 13.92 (4) (b) 7., Stats., Register December 2008 No. 636.

DHS 107.24 DHS 107.24 Durable medical equipment and medical supplies.

DHS 107.24(1) (1) Definition. In this section:

DHS 107.24(1)(a) (a) “Medical supplies” means disposable, consumable, expendable or nondurable medically necessary supplies which have a very limited life expectancy. Examples are plastic bed pans, catheters, electric pads, hypodermic needles, syringes, continence pads and oxygen administration circuits.

DHS 107.24(1)(b) (b) “Qualified health care professional” means any of the following:

DHS 107.24(1)(b)1. 1. A physician or physician assistant licensed under subch. II of ch. 448, Stats.

DHS 107.24(1)(b)2. 2. A physical therapist licensed under subch. III of ch. 448, Stats.

DHS 107.24(1)(b)3. 3. An occupational therapist licensed under subch. VII of ch. 448, Stats.

DHS 107.24(1)(b)4. 4. A chiropractor licensed under ch. 446, Stats.

DHS 107.24(2) (2) Covered services.

DHS 107.24(2)(a) (a) Prescription and provision.

DHS 107.24(2)(a)1. 1. Durable medical equipment (DME) and medical supplies, excluding complex rehabilitation technology identified in subd. 2., are covered services only when prescribed by a physician and when provided by a certified physician, clinic, hospital outpatient department, nursing home, pharmacy, home health agency, therapist, orthotist, prosthetist, hearing instrument specialist or medical equipment vendor.

DHS 107.24(2)(a)2. 2. Complex rehabilitation manual wheelchairs, power wheelchairs, and other seating components identified in the Wisconsin DME and medical supplies indices are covered services only when prescribed by a physician and when provided by a qualified complex rehabilitation technology supplier.

DHS 107.24(2)(b) (b) Items covered. Covered services are limited to items contained in the Wisconsin durable medical equipment (DME) and medical supplies indices. Items prescribed by a physician which are not contained in one of these indices or in the listing of non-covered services in sub. (5) require submittal of a DME additional request. Should the item be deemed covered, a prior authorization request may be required.

DHS 107.24(2)(c) (c) Categories of durable medical equipment. The following are categories of durable medical equipment covered by MA:

DHS 107.24(2)(c)1. 1. Occupational therapy assistive or adaptive equipment. This is medical equipment used to assist a person with a disability to adapt to the environment or achieve independence in performing daily personal functions. Examples are adaptive hygiene equipment, adaptive positioning equipment and adaptive eating utensils.

DHS 107.24(2)(c)2. 2. Orthopedic or corrective shoes. These are any shoes attached to a brace for prosthesis; mismatched shoes involving a difference of a full size or more; or shoes that are modified to take into account discrepancy in limb length or a rigid foot deformation. Arch supports are not considered a brace. Examples of orthopedic or corrective shoes are supinator and pronator shoes, surgical shoes for braces, and custom-molded shoes.

DHS 107.24(2)(c)3. 3. Orthoses. These are devices which limit or assist motion of any segment of the human body. They are designed to stabilize a weakened part or correct a structural problem. Examples are arm braces and leg braces.

DHS 107.24(2)(c)4. 4. Other home health care durable medical equipment. This is medical equipment used to increase the independence of a person with a disability or modify certain disabling conditions. Examples are patient lifts, hospital beds and traction equipment.

DHS 107.24(2)(c)5. 5. Oxygen therapy equipment. This is medical equipment used for the administration of oxygen or medical formulas or to assist with respiratory functions. Examples are a nebulizer, a respirator and a liquid oxygen system.

DHS 107.24(2)(c)6. 6. Physical therapy splinting or adaptive equipment. This is medical equipment used to assist a person with a disability to achieve independence in performing daily activities. Examples are splints and positioning equipment.

DHS 107.24(2)(c)7. 7. Prostheses. These are devices which replace all or part of a body organ to prevent or correct a physical disability or malfunction. Examples are artificial arms, artificial legs and hearing aids.

DHS 107.24(2)(c)8. 8. Wheelchairs. These are chairs mounted on wheels usually specially designed to accommodate individual disabilities and provide mobility. Examples are a standard weight wheelchair, a lightweight wheelchair and an electrically-powered wheelchair.

DHS 107.24(2)(c)9. 9. Complex rehabilitation technology. These are items identified in the Wisconsin DME and medical supplies indices which are updated to comply with s. 49.45 (9r) (a) 2., Stats.

DHS 107.24(2)(d) (d) Categories of medical supplies. Only approved items within the following generic categories of medical supplies are covered:

DHS 107.24(2)(d)1. 1. Colostomy, urostomy and ileostomy appliances;

DHS 107.24(2)(d)2. 2. Contraceptive supplies;

DHS 107.24(2)(d)3. 3. Diabetic urine and blood testing supplies;

DHS 107.24(2)(d)4. 4. Dressings;

DHS 107.24(2)(d)5. 5. Gastric feeding sets and supplies;

DHS 107.24(2)(d)6. 6. Hearing aid or other assistive listening devices batteries;

DHS 107.24(2)(d)7. 7. Incontinence supplies, catheters and irrigation apparatus;

DHS 107.24(2)(d)8. 8. Parenteral-administered apparatus; and

DHS 107.24(2)(d)9. 9. Tracheostomy and endotracheal care supplies.

DHS 107.24(3) (3) Services requiring prior authorization. All of the following services require prior authorization:

DHS 107.24(3)(a) (a) Purchase of all items indicated as requiring prior authorization in the Wisconsin DME and medical supplies indices, published periodically and distributed to appropriate providers by the department.

DHS 107.24(3)(b) (b) Repair or modification of an item which exceeds the department-established maximum reimbursement without prior authorization. Reimbursement parameters are published periodically in the DME and medical supplies provider handbook.

DHS 107.24(3)(c) (c) Purchase, rental, repair or modification of any item not contained in the current DME and medical supplies indices.

DHS 107.24(3)(d) (d) Purchase of items in excess of department-established frequencies or dollar limits outlined in the current Wisconsin DME and medical supplies indices.

DHS 107.24(3)(e) (e) The second and succeeding months of rental use, with the exception that all hearing aid or other assistive listening device rentals require prior authorization.

DHS 107.24(3)(f) (f) Purchase of any item which is not covered by Medicare, part b, when prescribed for a recipient who is also eligible for Medicare.

DHS 107.24(3)(g) (g) Any item required by a recipient in a nursing home which meets the requirements of sub. (4) (c).

DHS 107.24(3)(h) (h) Purchase or rental of a hearing aid or other assistive listening device in any of the following circumstances:

DHS 107.24(3)(h)1. 1. A request for prior authorization of a hearing aid or other ALD shall be reviewed only if the request consists of an otological report from the recipient’s physician and an audiological report from an audiologist or hearing instrument specialist, is on forms designated by the department and contains all information requested by the department. A hearing instrument specialist may perform an audiological evaluation and a hearing aid evaluation to be included in the audiological report if these evaluations are prescribed by a physician who determines all of the following:

DHS 107.24(3)(h)1.a. a. The recipient is over the age of 21.

DHS 107.24(3)(h)1.b. b. The recipient is not cognitively or behaviorally impaired.

DHS 107.24(3)(h)1.c. c. The recipient has no special need which would necessitate either the diagnostic tools of an audiologist or a comprehensive evaluation requiring the expertise of an audiologist.

DHS 107.24(3)(h)2. 2. After a new or replacement hearing aid or other ALD has been worn for a 30-day trial period, the recipient shall obtain a performance check from a certified audiologist, a certified hearing instrument specialist or at a certified speech and hearing center. The department shall provide reimbursement for the cost of the hearing aid or other ALD after the performance check has shown the hearing aid or ALD to be satisfactory, or 45 days has elapsed with no response from the recipient.

DHS 107.24(3)(h)3. 3. Special modifications other than those listed in the MA speech and hearing provider handbook shall require prior authorization.

DHS 107.24(3)(h)4. 4. Provision of services in excess of the life expectancies of equipment enumerated in the MA speech and hearing provider handbook require prior authorization, except for hearing aid or other ALD batteries and repair services.

DHS 107.24(3)(i) (i) A request for prior authorization of complex rehabilitation manual wheelchairs, complex rehabilitation power wheelchairs, and other complex rehabilitation seating components shall be reviewed only if the request consists of all of the following:

DHS 107.24(3)(i)1. 1. Documentation of a complex rehabilitative technology clinical evaluation performed by a qualified health care professional that includes all of the following:

DHS 107.24(3)(i)1.a. a. A detailed description of the qualified health care professional’s assessment as outlined in the provider handbook including identification of the specific complex rehabilitation technology items requested.

DHS 107.24(3)(i)1.b. b. A detailed description of the medical necessity as defined in ss. DHS 101.03 (96m) and 107.02 (3) (e), for each complex rehabilitation technology request.

DHS 107.24(3)(i)1.c. c. The qualified health care professional’s signature and date of completion.

DHS 107.24(3)(i)2. 2. Documentation stating that a direct, on-premises complex rehabilitation technology evaluation was performed by a qualified complex rehabilitation technology professional that includes all of the following:

DHS 107.24(3)(i)2.a. a. A detailed description of the recipient’s current durable medical equipment and requested complex rehabilitation technology items, the projected lifespan of both, the accessibility of the setting in which the requested items are to be used, the recipient’s applicable methods of transportation, and an analysis of at least one comparable alternative to each requested item including an explanation of why the alternative does not meet the recipient’s needs.

DHS 107.24(3)(i)2.b. b. A statement asserting that the qualified complex rehabilitation technology professional will provide appropriate training to the recipient and will maintain adequate documentation of the training provided.

DHS 107.24(3)(i)2.c. c. A statement indicating presence at the recipient’s complex rehabilitation technology clinical evaluation or other coordination with the qualified health care provider conducting the complex rehabilitation clinical evaluation to assist in selection of the most appropriate complex rehabilitation technology item.

DHS 107.24(3)(i)2.d. d. The qualified complex rehabilitation technology professional’s signature and date of completion.

DHS 107.24(3)(i)3. 3. A signed statement from each qualified health care professional, who performs the complex rehabilitation technology clinical evaluation, providing documentation of a complex rehabilitation technology clinical evaluation in subd. 1. indicating he or she does not have a financial relationship with the complex rehabilitation technology supplier providing the requested items.

DHS 107.24(3)(j) (j) A request for prior authorization of all complex rehabilitation technology not included in par. (i) shall be reviewed only if the request complies with MA policy and procedures as described in MA provider handbooks and bulletins and includes a detailed description of the medical necessity, as defined in s. DHS 101.03 (96m), of the complex rehabilitation technology requested.

DHS 107.24 Note Note: For more information on prior authorization, see s. DHS 107.02 (3).

DHS 107.24(4) (4) Other limitations.

DHS 107.24(4)(a) (a) Payment for medical supplies ordered for a patient in a medical institution is considered part of the institution’s cost and may not be billed directly to the program by a provider. Durable medical equipment and medical supplies provided to a hospital inpatient to take home on the date of discharge are reimbursed as part of the inpatient hospital services. No recipient may be held responsible for charges or services in excess of MA coverage under this paragraph.

DHS 107.24(4)(b) (b) Prescriptions shall be provided in accordance with s. DHS 107.02 (2m) (b) and may not be filled more than one year from the date the medical equipment or supply is ordered.

DHS 107.24(4)(c) (c) The services covered under this section are not covered for recipients who are nursing home residents except for:

DHS 107.24(4)(c)1. 1. Oxygen. Prescriptions for oxygen shall provide the required amount of oxygen flow in liters.

DHS 107.24(4)(c)2. 2. Durable medical equipment which is personalized in nature or custom-made for a recipient and is to be used by the recipient on an individual basis for hygienic or other reasons. These items are orthoses, prostheses including hearing aids or other assistive listening devices, orthopedic or corrective shoes, and complex rehabilitation technology. For coverage and reimbursement complex rehabilitation technology shall be prescribed by a physician, require prior authorization to establish medically necessity, and meet all complex rehabilitation standards under sub. (3) (i). In order to be covered for a recipient who is a nursing home resident, the complex rehabilitation technology shall do at least one of the following:

DHS 107.24(4)(c)2.a. a. Contribute to the recipient’s independent completion of activities of daily living.

DHS 107.24(4)(c)2.b. b. Support the recipient’s occupational, vocational, or psychosocial activities.

DHS 107.24(4)(c)2.c. c. Provide the recipient the independent ability to move about the facility, or to attain or retain self-care.

DHS 107.24(4)(d) (d) The provider shall weigh the costs and benefits of the equipment and supplies when considering purchase or rental of DME and medical supplies.

DHS 107.24 Note Note: The program’s listing of covered services and the maximum allowable reimbursement schedules are based on basic necessity. Although the program does not intend to exclude any manufacturer of equipment, reimbursement is based on the cost-benefit of equipment when comparable equipment is marketed at less cost. Several medical supply items are reimbursed according to generic pricing.

DHS 107.24(4)(e) (e) The department may determine whether an item is to be rented or purchased on behalf of a recipient. In most cases equipment shall be purchased; however, in those cases where short-term use only is needed or the recipient’s prognosis is poor, only rental of equipment shall be authorized.

DHS 107.24(4)(f) (f) Orthopedic or corrective shoes or foot orthoses shall be provided only for postsurgery conditions, gross deformities, or when attached to a brace or bar. These conditions shall be described in the prior authorization request.

DHS 107.24(4)(g) (g) Provision of hearing aid accessories shall be limited as follows:

DHS 107.24(4)(g)1. 1. For recipients under age 18: 3 earmolds per hearing aid, 2 single cords per hearing aid and 2 Y-cords per recipient per year;

DHS 107.24(4)(g)2. 2. For recipients over age 18: one earmold per hearing aid, one single cord per hearing aid and one Y-cord per recipient per year; and

DHS 107.24(4)(g)3. 3. For all recipients: one harness, one contralateral routing of signals (CROS) fitting, one new receiver per hearing aid and one bone-conduction receiver with headband per recipient per year.

DHS 107.24(4)(h) (h) If a prior authorization request is approved, the person shall be eligible for MA reimbursement for the service on the date the final ear mold is taken.

DHS 107.24(4)(i) (i) Reimbursement for complex rehabilitation technology is limited to qualified complex rehabilitation technology suppliers.

DHS 107.24(4)(j) (j) The cost of mailing or delivery, such as shipping and handling charges and fees, of diagnostic tools or equipment needed to assess, diagnose, repair or setup medical supplies, hearing aids, cochlear implants, or other equipment cannot be billed to the recipient.

DHS 107.24(5) (5) Non-covered services. The following services are not covered services: