WAC 388-543-1100   Scope of coverage and coverage limitations for DME and related supplies, prosthetics, orthotics, medical supplies and related services.  The federal government deems durable medical equipment (DME) and related supplies, prosthetics, orthotics, and medical supplies as optional services under the medicaid program, except when prescribed as an integral part of an approved plan of treatment under the home health program or required under the early and periodic screening, diagnosis and treatment (EPSDT) program. The department may reduce or eliminate coverage for optional services, consistent with legislative appropriations.

     (1) The department covers DME and related supplies, prosthetics, orthotics, medical supplies, related services, repairs and labor charges when they are:

     (a) Within the scope of an eligible client's medical care program (see WAC 388-501-0060 and 388-501-0065);

     (b) Within accepted medical or physical medicine community standards of practice;

     (c) Prior authorized as described in WAC 388-543-1600, 388-543-1800, and 388-543-1900;

     (d) Prescribed by a physician, advanced registered nurse practitioner (ARNP), or physician assistant certified (PAC). Except for dual eligible medicare/medicaid clients when medicare is the primary payer and the department is being billed for co-pay and/or deductible only:

     (i) The prescriber must use DSHS 13-794 (Health and Recovery Services (HRSA) Prescription Form) to write the prescription. The form is available for download at http://www1.dshs.wa.gov/msa/forms/eforms.html; and;

     (ii) The prescription (DSHS 13-794) must:

     (A) Be signed and dated by the prescriber;

     (B) Be no older than one year from the date the prescriber signs the prescription; and

     (C) State the specific item or service requested, diagnosis, estimated length of need (weeks, months, or years), and quantity;

     (e) Billed to the department as the payor of last resort only. The department does not pay first and then collect from medicare and;

     (f) Medically necessary as defined in WAC 388-500-0005. The provider or client must submit sufficient objective evidence to establish medical necessity. Information used to establish medical necessity includes, but is not limited to, the following:

     (i) A physiological description of the client's disease, injury, impairment, or other ailment, and any changes in the client's condition written by the prescribing physician, ARNP, PAC, licensed prosthetist and/or orthotist, physical therapist, occupational therapist, or speech therapist; and/or

     (ii) Video and/or photograph(s) of the client demonstrating the impairments as well and client's ability to use the requested equipment, when applicable.

     (2) The department evaluates a request for any equipment or device listed as noncovered in WAC 388-543-1300 under the provisions of WAC 388-501-0160.

     (3) The department evaluates a request for a service that is in a covered category, but has been determined to be experimental or investigational under WAC 388-531-0550, under the provisions of WAC 388-501-0165.

     (4) The department evaluates requests for covered services in this chapter that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions under the provisions of WAC 388-501-0165 and 388-501-0169.

     (5) The department does not reimburse for DME and related supplies, prosthetics, orthotics, medical supplies, related services, and related repairs and labor charges under fee-for-service (FFS) when the client is any of the following:

     (a) An inpatient hospital client;

     (b) Eligible for both medicare and medicaid, and is staying in a nursing facility in lieu of hospitalization;

     (c) Terminally ill and receiving hospice care; or

     (d) Enrolled in a risk-based managed care plan that includes coverage for such items and/or services.

     (6) The department covers medical equipment and related supplies, prosthetics, orthotics, medical supplies and related services, repairs, and labor charges listed in the department's published issuances, including Washington Administrative Code (WAC), billing instructions, and numbered memoranda.

     (7) An interested party may request the department to include new equipment/supplies in the billing instructions by sending a written request plus all of the following:

     (a) Manufacturer's literature;

     (b) Manufacturer's pricing;

     (c) Clinical research/case studies (including FDA approval, if required); and

     (d) Any additional information the requester feels is important.

     (8) The department bases the decision to purchase or rent DME for a client, or to pay for repairs to client-owned equipment on medical necessity.

     (9) The department covers replacement batteries for purchased medically necessary DME equipment covered within this chapter.

     (10) The department covers the following categories of medical equipment and supplies only when they are medically necessary, prescribed by a physician, ARNP, or PAC, are within the scope of his or her practice as defined by state law, and are subject to the provisions of this chapter and related WACs:

     (a) Equipment and supplies prescribed in accordance with an approved plan of treatment under the home health program;

     (b) Wheelchairs and other DME;

     (c) Prosthetic/orthotic devices;

     (d) Surgical/ostomy appliances and urological supplies;

     (e) Bandages, dressings, and tapes;

     (f) Equipment and supplies for the management of diabetes; and

     (g) Other medical equipment and supplies listed in department published issuances.

     (11) The department evaluates a BR item, procedure, or service for its medical appropriateness and reimbursement value on a case-by-case basis.

     (12) For a client in a nursing facility, the department covers only the following when medically necessary. All other DME and supplies identified in the department's billing instructions are the responsibility of the nursing facility, in accordance with chapters 388-96 and 388-97 WAC. See also WAC 388-543-2900 (3) and (4).

     (a) The department covers:

     (i) The purchase and repair of a speech generating device (SGD) and one of the following:

     (A) A powered or manual wheelchair for the exclusive full-time use of a permanently disabled nursing facility resident when the wheelchair is not included in the nursing facility's per diem rate; or

     (B) A specialty bed or the rental of a specialty bed outside of the skilled nursing facility per diem when:

     (I) The specialty bed is intended to help the client heal; and

     (II) The client's nutrition and laboratory values are within normal limits.

     (b) A heavy duty bariatric bed is not considered a specialty bed.

     (13) Vendors must provide instructions for use of equipment; therefore, instructional materials such as pamphlets and video tapes are not covered.

     (14) Bilirubin lights are limited to rentals, for at-home newborns with jaundice.



[Statutory Authority: RCW 74.08.090 and 74.04.050. 07-17-062, § 388-543-1100, filed 8/13/07, effective 9/13/07. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. 06-24-036, § 388-543-1100, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.04.050, 74.04.57 [74.04.057], and 74.08.090. 05-21-102, § 388-543-1100, filed 10/18/05, effective 11/18/05. Statutory Authority: RCW 74.08.090, 34.05.353. 03-12-005, § 388-543-1100, filed 5/22/03, effective 6/22/03. Statutory Authority: RCW 74.08.090, 74.09.530. 02-16-054, § 388-543-1100, filed 8/1/02, effective 9/1/02; 01-01-078, § 388-543-1100, filed 12/13/00, effective 1/13/01.]