(1) These requirements are in addition to those contained in rule provisions generally applicable to Medicaid providers. Requirements for prosthetic devices, durable medical equipment, and medical supplies utilized by nursing facility residents are contained in the department's rules governing nursing facility reimbursement when the nursing facility bills for separately billable items as a skilled nursing durable medical equipment provider as outlined in ARM 37.40.330.
(2) Reimbursement for prosthetic devices, durable medical equipment, and medical supplies shall be limited to items delivered in the most appropriate and cost effective manner. Montana Medicaid adopts 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) dated January 2011. For prosthetic devices, durable medical equipment, and medical supplies not covered by Medicare coverage will be determined by the department. The items must be medically necessary and prescribed in accordance with (2)(a) by a physician or other licensed practitioner of the healing arts within the scope of his practice as defined by state law.
(a) The prescription must indicate the diagnosis, the medical necessity, and projected length of need for prosthetic devices, durable medical equipment, and medical supplies. The original prescription must be retained in accordance with the requirements of ARM 37.85.414. Prescriptions may be transmitted by an authorized provider to the durable medical equipment provider by electronic means or pursuant to an oral prescription made by an individual practitioner and promptly reduced to hard copy by the durable medical equipment provider containing all information required. Prescriptions for durable medical equipment, prosthetics, and orthotics (DMEPOS) shall follow the Medicare criteria outlined in chapters 3 and 4 of the Region D Medicare Supplier Manual (January 1, 2011), which is adopted and incorporated by reference. A copy of the Region D Medicare Supplier Manual may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT 59620-2951. For items requiring prior authorization the provider must include a copy of the prescription when submitting the prior authorization request.
(i) Prescriptions for oxygen shall include the liter flow per minute, the hours of use per day, and the recipient's PO2 or oxygen saturation blood test(s) results.
(b) Subject to the provisions of (3), medical necessity for oxygen is determined in accordance with the Medicare criteria outlined in the Medicare Durable Medical Equipment Regional Carrier (DMERC) Region D Supplier Manual, (January 1, 2011), Local Coverage Determination (LCD) and policy articles (January 1, 2011), and National Coverage Determination (NCD) (January 1, 2011), which are adopted and incorporated by reference. The Medicare criteria specify the health conditions and levels of hypoxemia in terms of blood gas values for which oxygen will be considered medically necessary. The Medicare criteria also specify the medical documentation and laboratory evidence required to support medical necessity. A copy of the Medicare criteria may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT 59620-2951.
(c) Reimbursement for oxygen is made on a monthly basis. Only one unit may be billed per month regardless of the actual amount used by the patient.
(d) A statement of medical necessity for the rental of durable medical equipment, excluding oxygen equipment, shall indicate the length of time the equipment will be needed. All prescriptions shall be signed and dated.
(e) No more than one month's medical supplies may be provided to a Medicaid recipient based on the physician's orders.
(f) A determination of the medical necessity of an item made by the Medicare program is applicable to the Medicaid program.
(g) Recipients shall be limited to a new wheelchair no more than once every five years, unless the department determines that a new chair is required sooner because the recipient's current chair is causing the recipient serious health problems or because of a significant change in the recipient's medical condition.
(3) Providers of oxygen to recipients for whom oxygen was determined to be medically necessary prior to the adoption of the Medicare criteria, effective March 1, 1998, set forth in (2) may be reimbursed for oxygen services to those recipients, even though the oxygen would not be medically necessary for them under the Medicare criteria, until the recipient's next recertification of medical necessity.
(4) Reimbursement for out-of-home use includes:
(a) medically necessary wheelchair tie downs and head rests for transportation to work or school and laterals and flat free inserts required for activities in the workplace or at school used by children age 20 and under; and
(b) medically necessary wheelchair tie downs and head rests for transportation outside the home to go to work or school and laterals and flat free inserts used by adults in the workplace or at school.
(5) Reimbursement for nursing home residents includes:
(a) medically necessary custom molded wheelchair positioning equipment used by nursing home residents not covered under nursing home per diem (see department nursing home rules). A copy of the Medicaid criteria may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT 59620-2951.
(6) The following items are not reimbursable by the program:
(a) items determined not to be medically necessary by the Medicare program, except as provided in (3);
(b) orthopedic shoes, corrections, and shoe repairs unless the criteria in (6)(b)(i) or (ii) are met and the physician's prescription indicates that:
(i) the shoes are attached to a brace or orthotic device which cannot be accommodated in a regular shoe; or
(ii) the shoes are covered under Medicare criteria for therapeutic shoes for diabetics under the same conditions the Medicare program will cover therapeutic shoes for diabetics. A copy of the Medicare criteria is available upon request from the Department of Public Health and Human Services, Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT 59620-2951;
(c) convenience and comfort items;
(d) payment for provider's travel;
(e) nutrient solutions except when they are for parenteral and enteral nutrition therapy, are the primary source of nutrition for patients, and are medically appropriate;
(f) purchase of air fluidized beds;
(g) any delivery, mailing or shipping fees, or other costs of transporting the item to the recipient's location;
(h) disposable incontinence wipes;
(i) adaptive equipment;
(j) building modifications;
(k) automobile modifications;
(l) environmental control devices;
(m) exercise equipment;
(n) personal care items;
(p) educational equipment;
(q) personal computers;
(r) sexual aids or devices;
(s) items included in the nursing home per diem rate; and
(t) backup equipment.
(7) 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.