Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 78 - Amount, Duration and Scope of Medical and Remedial Services › Rule 441-78.10 - Durable Medical Equipment (DME) , Prosthetic Devices and Medical Supplies

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
General payment requirements.
Payment will be made for items
				of DME, prosthetic devices and medical supplies, subject to the following
				general requirements and the requirements of subrule 78.10(2), 78.10(3), or
				78.10(4), as applicable:
a. DME, prosthetic
				devices, and medical supplies must be required by the member because of the
				member's medical condition.
b. The
				item shall be necessary and reasonable either for the treatment of an illness
				or injury, or to improve the functioning of a malformed body part.
				Determination will be made by the Iowa Medicaid enterprise medical services
				unit.
(1) An item is necessary when it can be
				expected to make a meaningful contribution to the treatment of a specific
				illness or injury or to the improvement in function of a malformed body
				part.
(2) Although an item may be
				necessary, it must also be a reasonable expenditure for the Medicaid program.
				The following considerations enter into the determination of reasonableness:
				Whether the expense of the item to the program would be clearly
				disproportionate to the therapeutic benefits which could ordinarily be derived
				from use of the item; whether the item would be substantially more costly than
				a medically appropriate and realistically feasible alternative pattern of care;
				and whether the item serves essentially the same purpose as an item already
				available to the beneficiary.
c. A physician's (doctor of medicine,
				osteopathy, or podiatry), physician assistant's, or advanced registered nurse
				practitioner's prescription is required to establish medical necessity. The
				prescription shall state the member's name, diagnosis, prognosis, item(s) to be
				dispensed, quantity, and length of time the item is to be required and shall
				include the signature of the prescriber and the date of signature.
For items requiring prior authorization, a request shall
				  include a physician's, physician assistant's, or advanced registered nurse
				  practitioner's written order or prescription and sufficient medical
				  documentation to permit an independent conclusion that the requirements for the
				  equipment or device are met and the item is medically necessary and reasonable.
				  A request for prior authorization is made on Form 470-0829, Request for Prior
				  Authorization. See rule
				  441-78.28 (249A) for prior
				  authorization requirements.
d. Nonmedical items will not be covered.
				These include but are not limited to:
(1)
				Physical fitness equipment, e.g., an exercycle, weights.
(2) First-aid or precautionary-type
				equipment, e.g., preset portable oxygen units.
(3) Self-help devices, e.g., safety grab
				bars, raised toilet seats.
(4)
				Training equipment, e.g., speech teaching machines, braille training
				texts.
(5) Equipment used for
				environmental control or to enhance the environmental setting, e.g., room
				heaters, air conditioners, humidifiers, dehumidifiers, and electric air
				cleaners.
(6) Equipment which
				basically serves comfort or convenience functions or is primarily for the
				convenience of a person caring for the member, e.g., elevators, stairway
				elevators and posture chairs.
e. The amount payable is based on the least
				expensive item which meets the member's medical needs. Payment will not be
				approved for items that serve duplicate functions. EXCEPTION: A second
				ventilator for which prior authorization has been granted. See
				78.10(5)
"k"
for prior authorization requirements.
f. Consideration will be given to rental or
				purchase based on the price of the item and the length of time it would be
				required. The decision on rental or purchase shall be made by the Iowa Medicaid
				enterprise and be based on the most reasonable method to provide the equipment.
(1) The provider shall monitor rental
				payments up to 100 percent of the purchase price. At the point that total rent
				paid equals 100 percent of the purchase allowance, the member will be
				considered to own the item and no further rental payments will be made to the
				provider.
(2) Payment may be made
				for the purchase of an item even though rental payments may have been made for
				prior months. The rental of the equipment may be necessary for a period of time
				to establish that it will meet the identified need before the purchase of the
				equipment. When a decision is made to purchase after renting an item, all of
				the rental payments will be applied to the purchase allowance.
(3) Exception: Ventilators and oxygen systems
				shall be maintained on a rental basis for the duration of use.
(4) A deposit shall not be charged by a
				provider to a Medicaid member or any other person on behalf of a Medicaid
				member for rental of medical equipment.
g. Payment may be made for necessary repair,
				maintenance, and supplies for member-owned equipment. No payment may be made
				for repairs, maintenance, or supplies when the member is renting the
				item.
h. Replacement of
				member-owned equipment is covered in cases of loss or irreparable damage or
				when required because of a change in the member's condition.
i. No allowance will be made for delivery,
				freight, postage, or other provider operating expenses for DME, prosthetic
				devices or medical supplies.
j.
				Reimbursement over the established fee schedule amount is allowed when prior
				authorization has been obtained. See 78.10(5)
"n "
for prior
				authorization requirements.