Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 27 - Department of Medical Services › Rule 016.27.20-013 - Hyperalimentation 1-19, Prosthetics 3-19, and State Plan Amendment 2020-0017

Current through Register Vol. 49, No. 6, June, 2024
Section II
			 Prosthetics
212.209
(DME) Low-Profile
			 Skin Level Gastrostomy Tube (Low-Profile Button) and Supplies for Beneficiaries
			 of All Ages
The Arkansas Medicaid Program reimburses for the Low-Profile
				Skin Level Gastrostomy Tube (Low-Profile Button) and supplies for
				Medicaid-eligible beneficiaries of all ages. Prior authorization (PA) from DHS
				or its designated vendor is required.
When requesting prior authorization, form DMS-679A titled
Prescription & Prior Authorization Request for Medical Equipment
				Excluding Wheelchairs & Wheelchair Components,
must be completed
				and sent, along with sufficient medical documentation.
View
				or print contact information for how to submit the
				request.
The Low-Profile Kit is benefit-limited to two (2) per state
				fiscal year (SFY). The accessories, extension sets, and adapters are covered
				under the $250 medical supply benefit limit.
Benefit extensions will be considered on a case-by-case basis
				if proven to be medically necessary.
212.210
DME Low-Profile Percutaneous
			 Cecostomy Tube (Low-Profile Button) for Beneficiaries of All Ages
The Low-Profile Button for a Percutaneous Cecostomy Tube
				requires use of the following diagnosis codes.
(View ICD
				codes.)
The Low-Profile Button for a Percutaneous Cecostomy Tube
				requires use of the following CPT codes:
44300
49442
49450
242.150
Nutritional Formulae for Child
			 Health Services (EPSDT)
Beneficiaries Under Twenty-one (21) Years of
				Age
The following list provides the enteral formula HCPCS procedure
				codes, any associated modifiers, code descriptions, and the formula covered for
				each HCPCS code. The code description lists the formula included in the
				category of nutrients.
The coverage listed is payable only if the service is
				prescribed as a result of a Child Health Services (EPSDT)
				screening/referral.
No prior authorization is required for nutritional formulae for
				EPSDT beneficiaries from age five (5) years through twenty (20) years.
Prior authorization is required for beneficiaries from birth
				through four (4) years. Use of modifier
U7
in the following list
				will be necessary, as indicated.
To request prior authorization, providers should complete the
Prescription & Prior Authorization Request for Medical Equipment
				Excluding Wheelchairs & Wheelchair Components
(DMS-679A),
				attaching a copy of the EPSDT screening/referral as well as a prescription
				signed by the beneficiary's PCP.
View or print form
				DMS-679A
.
View or print contact information for how to
				submit the request.
NOTE: The Women, Infant, and Children program (WIC) must
				be accessed before the Medicaid program for children from birth to five (5)
				years of age.
The Arkansas Medicaid program mirrors coverage of
				approved WIC nutritional formulae. As stated in current policy, the WIC Program
				must be accessed first for Arkansas Medicaid beneficiaries aged zero (0) to
				five (5) years, prior to requesting
supplemental amounts of WIC-approved nutritional formula.
				The Medicaid nutritional formula list will be updated accordingly to continue
				compliance with the WIC Program in Arkansas. Changes will be reflected in the
				appropriate Medicaid provider manual.
For beneficiaries from birth through four (4) years of age, the
				use of modifier U8, as well as additional documentation, will be required when
				a non-WIC formula is prescribed, or WIC guidelines are not followed when
				prescribing special formula.
An EPSDT screening, which documents the PCP's medical rationale
				for prescribing a formula, as well as medical records documenting the
				beneficiary's failed trials of WIC formula, must be submitted for review.
				Flavor preferences for formulae will not be considered for medical
				necessity.
Exceptions to Use of
				Formulae
The following exceptions must be followed in order to use
				formulae listed in this section.
A.
			 Nutramigen LIPIL - Sensitivity or allergy to milk or soy protein; chronic
			 diarrhea, food allergies, Gl bleeds. Similac Advance must first have been
			 tried.
B. Nutramigen Enflora LGG -
			 Sensitivity or allergy to milk or soy protein; chronic diarrhea, food
			 allergies, Gl bleeds. Similac Advance must first have been tried.
C. Pregestimil - Allergy to milk or soy
			 protein; chronic diarrhea, short gut; cystic fibrosis; fat malabsorption due to
			 Gl or liver disease.
D. Gerber
			 Extensive HA - Allergy to milk or soy protein; severe malnutrition; chronic
			 diarrhea; short bowel syndrome; known or suspected corn allergy. Similac
			 Advance must first have been tried.
E. Alfamino Junior - Allergy to cow's milk,
			 multiple food protein intolerance, and food allergy associated conditions:
			 short bowel syndrome, gastroesophageal reflux disease (GERD), eosinophilic
			 esophagitis, malabsorption, and other Gl disorders. Neocate Junior with
			 Prebiotics is intended for children over the age of one (1) year.
F. Alfamino Infant - Allergy to cow's milk,
			 multiple food protein intolerance, and food allergy associated conditions:
			 short bowel syndrome, gastroesophageal reflux disease (GERD), eosinophilic
			 esophagitis, malabsorption, and other Gl disorders. Similac Expert Care
			 Alimentum, Nutramigen, or Pregestimil must first have been tried.
G. Portagen - Pancreatic insufficiency, bile
			 acid deficiency, or lymphatic anomalies; biliary atresia; liver disease;
			 chylothorax.
H. Similac PM 60/40 -
			 Renal, cardiac, or other condition that requires lowered minerals.
I. Periflex Infant - PKU;
			 Hyperphenylalaninemia; for infants and toddlers.
J. PKU Periflex Junior Plus -
			 Hyperphenylalaninemia; for children and adults.
K. Gerber Good Start Premature 24- Preterm,
			 low birth weight. Not intended for feeding low birth weight infants after they
			 reach a weight of 3600 g (approximately eight (8) lbs.). Not approved for an
			 infant previously on term formula or a term infant for increased
			 calories.
L. Enfamil EnfaCare -
			 Preterm infant transitional formula for use between premature formula and term
			 formula. Not approved for an infant previously on term formula or a term infant
			 for increased calories.
Procedure codes found in this section must be billed either
				electronically or on paper with modifier
EP
for beneficiaries
				under twenty-one (21) years of age. Modifier BO is used to bill for oral usage.
				When a second or third modifier is listed, that modifier must be used in
				conjunction with EP.
For beneficiaries from birth through four (4) years of age, the
				use of modifier U7, as well as additional documentation will be required when a
				non-WIC formula is prescribed, or WIC guidelines are not followed when
				prescribing special formula.
Modifiers in this section are indicated by the headings M1, M2,
				M3 and M4.
Nutritional Formulae for Child Health Services (EPSDT)
				Beneficiaries Under Twenty-one (21) Years of Age (Section 242.150
				)
National Procedure Code
M1
M2
M3
M4
Description
Covered Formulae
B4149 B4149
B4149 B4149
Ages 0-4 Years requires PA
B4150 B4150
B4150 B4150
Ages 0-4 Years requires PA
EP EP
EP EP
EP EP
EP EP
BO
U7 U7
BO
U7 U7
BO BO
Enteral formula, blenderized natural foods with intact
						  nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may
						  include fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
Enteral formula, nutritionally complete with intact
						  nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may
						  include fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
B4150
B4150
Ages 0-4 Years requires PA
EP EP
U1 U1
BO U7
BO
Enteral formula, nutritionally complete with intact
						  nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may
						  include fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
B4152 B4152
B4152 B4152
Ages 0-4 Years requires PA
EP EP
EP EP
BO
U7 U7
BO
Enteral formula, nutritionally complete, calorically
						  dense (equal to or greater than 1.5 Kcal/ml), with intact nutrients, includes
						  proteins, fats, carbohydrates, vitamins, and minerals, may include fiber,
						  administered through an enteral feeding tube, 100 calories = 1 unit
B4153 B4153
B4153 B4153
Ages 0-4 Years requires PA
EP EP
EP EP
BO
U7 U7
BO
Enteral formula, nutritionally complete, hydrolyzed
						  proteins (amino acids and peptide chain), includes fats, carbohydrates,
						  vitamins, and minerals, may include fiber, administered through an enteral
						  feeding tube, 100 calories = 1 unit
B4154 B4154
B4154 B4154
Ages 0-4 Years requires PA
EP EP
EP EP
BO
U7 U7
BO
Enteral formula, nutritionally complete, for special
						  metabolic needs, includes inherited disease of metabolism, includes altered
						  composition of proteins, fats, carbohydrates, vitamins, or minerals, may
						  include fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
B4155 B4155
Bill on paper (Indicate specific name of formula on
						  claims.)
EP EP
BO ate
Enteral formula, nutritionally incomplete/modular
						  nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers),
						  proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain
						  triglycerides), or combination, administered through an enteral feeding tube,
						  100 calories = 1 unit
MCT Oil Procel Protein Supplement Provimin
B4155 B4155
Ages 0-4 Years requires PA
Bill on paper (Indicate specific name of formula on
						  claims.)
EP EP
U7 ate
BO
Enteral formula, nutritionally incomplete/modular
						  nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers),
						  proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain
						  triglycerides), or combination, administered through an enteral feeding tube,
						  100 calories = 1 unit
MCT Oil Procel Protein Supplement Provimin
B4155 B4155
B4155 B4155
Ages 0-4 Years requires PA
EP EP
EP EP
U1 U1
U1 U1
BO
U7 U7
BO
Enteral formula, nutritionally incomplete/modular
						  nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers),
						  proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain
						  triglycerides), or combination, administered through an enteral feeding tube,
						  100 calories = 1 unit
SolCarb Scandical
B4155 B4155
B4155 B4155
Ages 0-4 Years requires PA
EP EP
EP EP
U2 U2
U2 U2
BO
U7 U7
BO
Enteral formula, nutritionally incomplete/modular
						  nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers),
						  proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain
						  triglycerides), or combination, administered through an enteral feeding tube,
						  100 calories = 1 unit
Microlipid
B4155 B4155
B4155 B4155
Ages 0-4 Years requires PA
EP EP
EP EP
U3 U3
U3 U3
BO
U7 U7
BO
Enteral formula, nutritionally incomplete/modular
						  nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers),
						  proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain
						  triglycerides), or combination, administered through an enteral feeding tube,
						  100 calories = 1 unit
B4158 B4158
B4158 B4158
Ages 0-4 Years requires PA
EP EP
EP EP
BO
U7 U7
BO
Enteral formula, for pediatrics, nutritionally complete
						  with intact nutrients, includes proteins, fats, carbohydrates, vitamins and
						  minerals, may include fiber, or iron, administered through an enteral feeding
						  tube, 100 calories = 1 unit
B4159 B4159
B4159 B4159
Ages 0-4 Years requires PA
EP EP
EP EP
BO
U7 U7
BO
Enteral formula, for pediatrics, nutritionally complete
						  soy base with intact nutrients, includes proteins, fats, carbohydrates,
						  vitamins and minerals, may include fiber, or iron, administered through an
						  enteral feeding tube, 100 calories = 1 unit
B4159 B4159
B4159 B4159
Ages 0-4 Years requires PA
EP EP
EP EP
BO
U8 U8
U7 U7
BO
Enteral formula, for pediatrics, nutritionally complete
						  soy base with intact nutrients, includes proteins, fats, carbohydrates,
						  vitamins and minerals, may include fiber, or iron, administered through an
						  enteral feeding tube, 100 calories = 1 unit
B4160 B4160
B4160 B4160
Ages 0-4 Years requires PA
EP EP
EP EP
BO
U7 U7
BO
Enteral formula, for pediatrics, nutritionally complete
						  calorically dense (equal to or greater than 0.7Kcal/ml) with intact nutrients,
						  includes proteins, fats, carbohydrates, vitamins, and minerals, may include
						  fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
B4160 B4160
B4160 B4160
Ages 0-4 Years requires PA
EP EP
EP EP
BO
U8 U8
U7 U7
BO
Enteral formula, for pediatrics, nutritionally complete
						  calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients,
						  includes proteins, fats, carbohydrates, vitamins, and minerals, may include
						  fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
B4160 B4160
B4160 B4160
Ages 0-4 Years requires PA
EP EP
EP EP
U1 U1
U1 U1
BO
U7 U7
BO
Enteral formula, for pediatrics, nutritionally complete
						  calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients,
						  includes proteins, fats, carbohydrates, vitamins, and minerals, may include
						  fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
B4160 B4160
Ages 0-4 Years requires PA
EP EP
U1 U1
U8 U8
BO
Enteral formula, for pediatrics, nutritionally complete
						  calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients,
						  includes proteins, fats, carbohydrates, vitamins, and minerals, may include
						  fiber, administered through an enteral feeding tube, 100 calories = 1
						  unit
B4161 B4161
B4161 B4161
Ages 0-4 Years requires PA
EP EP
EP EP
BO
U7 U7
BO
Enteral formula, for pediatrics,
hydrolyzed/amino acids and peptide chain proteins,
						  includes fats, carbohydrates, vitamins, and minerals, may include fiber,
						  administered through an enteral feeding tube, 100 calories = 1 unit
B4161 B4161
B4161 B4161
Ages 0-4 Years requires PA
EP EP
EP EP
BO
U7 U7
U8 U8
BO
Enteral formula, for pediatrics,
hydrolyzed/amino acids and peptide chain proteins,
						  includes fats, carbohydrates, vitamins, and minerals, may include fiber,
						  administered through an enteral feeding tube, 100 calories = 1 unit
B4162 B4162
B4162 B4162
Ages 0-4 Years requires PA
EP EP
EP EP
BO
U7 U7
BO
Enteral formula, for pediatrics, special metabolic
						  needs for inherited disease of metabolism, includes fats, carbohydrates,
						  vitamins, and minerals, may include fiber, administered through an enteral
						  feeding tube, 100 calories = 1 unit
B4162 B4162
B4162 B4162
Ages 0-4 Years requires PA
EP EP
EP EP
U1 U1
U1 U1
BO
U7 U7
BO
Enteral formula, for pediatrics, special metabolic
						  needs for inherited disease of metabolism, includes fats, carbohydrates,
						  vitamins, and minerals, may include fiber, administered through an enteral
						  feeding tube, 100 calories = 1 unit
One (1) unit of service equals one-hundred (100) calories with
				a reimbursable maximum of thirty (30) units per day. Supplies furnished by
				prosthetics providers in conjunction with the nutritional formula must be
				billed to Medicaid with the prosthetics medical supply codes. These formulae
				are covered as nutritional supplements rather than as the sole source of
				nutrition.
NOTE: Beneficiaries who require enteral nutrition as the
				sole source of nutrition with the formulae being administered through a
				nasogastric, jejunostomy or gastrostomy tube should be referred to a
				hyperalimentation provider enrolled in the Medicaid Program.
Each claim should reflect a "from" and "through" date of
				service. The claims must not be filed until after the "through" date has
				elapsed. Claims may be submitted on either a weekly or a monthly
				basis.
242.153
Low-Profile Skin Level Gastrostomy Tube (Low-Profile Button) and
			 Low-Profile Percutaneous Cecostomy Tube and Supplies for Beneficiaries of All
			 Ages
NOTE: When billing for the Low-Profile Percutaneous
				Cecostomy Tube or supplies, an additional third modifier UA will be
				required.
Modifiers in this section are indicated by the headings M1 and
				M2. Prior authorization requirements are shown under the heading PA.
National Procedure Code
M1
M2
PA
Description
Payment Method
B9998
Y
Low-Profile Kit
Purchase
B9998
NU
U1
Y
SECUR-LOK Extension Set with 2 Port 'Y' and Clamp 12"
						  Length
Purchase
B9998
NU
U2
Y
SECUR-LOK Extension Set with 2 Port 'Y' and Clamp 24"
						  Length
Purchase
B9998
NU
U3
Y
Bolus Extension Set with Single Port Clamp 12"
						  Length
Purchase
B9998
NU
U4
Y
Bolus Extension Set with Single Port Clamp 24"
						  Length
Purchase
B9998
NU
U5
Y
Bolus SECUR-LOK Extension Set Single Portw/Clamp 12"
						  Length
Purchase
B9998
NU
U6
Y
Bolus SECUR-LOK Extension Set Single Port w/Clamp 24"
						  Length
Purchase
B9998
NU
U7
Y
Microvasive Adapter
Purchase
B9998
NU
U8
Y
Microvasive Decompression Tube
Purchase