California
Durable Medical Equipment.
22 CCR 51321
Source text
48 segments
22 CCR 51321
22 CCR 51321
§ 51321. Durable Medical Equipment.
(a)
Durable medical equipment, as defined in Section 51160, is covered in accordance with the standards set forth in section 51303(a) and when provided on the written prescription of licensed practitioners within the scope of their practice as established in California law. Alterations or improvements of real property are not covered except to the extent authorized for the provision of home dialysis services. In addition to the prescribing practitioner's signature, all of the following specific information, at a minimum, shall be clearly provided on, or with the prescription form, or as an attachment to the Treatment Authorization Request:
(1)
Full name and telephone number of the prescribing practitioner.
(2)
Date of prescription.
(3)
Specific item(s) being prescribed.
(4)
Patient's medical condition/diagnosis necessitating each item. This documentation shall include:
(A)
The patient's medical status and functional limitation(s) and
(B)
A description of the manner in which the specific item being requested is expected to improve the medical status or functional ability of the patient, stabilize the patient's condition, or prevent additional deterioration of the medical status or functional ability of the patient.
(5)
Estimated length of time the item is determined to be medically necessary.
(b)
Prior authorization is required:
(1)
For the purchase of durable medical equipment listed in Section 51521 when the cumulative cost within the calendar month of purchasing items within a group exceeds $100.00.
(2)
For the repair or maintenance of durable medical equipment when the cumulative cost within the calendar month exceeds $250.00 for the repair and maintenance of items within a group, and when the cumulative cost of renting items within a group exceeds $50.00 within a fifteen month period. The cost of repairs shall not exceed the replacement value of the item being repaired.
(3)
For the provision of oxygen, Procedure Code E0441, when more than the equivalent of two H tanks (which equals 10 “E” tanks or 500 cu. ft.) are provided during one calendar month.
(4)
For the purchase, rental, repair or maintenance of any unlisted devices or equipment, regardless of the dollar amount.
(c)
All authorization requests shall, at a minimum, include all of the following:
(1)
Identification of patient; name and patient Medi-Cal identification or Social Security number.
(2)
Date of request.
(3)
Medical justification relevant to the item being requested.
(4)
Location where patient resides.
(5)
Description of item, including:
(A)
Manufacturer's name and/or model type/serial number, as applicable.
(B)
Procedure Code.
(C)
Estimated length of need, whether rental or purchase of the item is requested, and associated charges. Except for life support equipment, such as ventilators, and other equipment that requires ongoing service or maintenance, when previously paid rental charges equal the maximum allowable purchase price of the rented item, as specified in Section 51521(i), the item is considered to have been purchased and no further reimbursement to the provider shall be made unless repair or maintenance of the item is separately authorized. When the Department determines it is medically necessary to purchase an unlisted item of durable medical equipment that had been rented for a Medi-Cal patient, the Department and the provider shall determine the purchase price and the amount of the rental charges that may be applied to the purchase price.
(6)
Rendering provider identification, including name, address, telephone number, contact name, contact telephone number, and Medi-Cal provider I.D. number.
(d)
In addition to the documentation requirements specified in (c) above, authorization requests for unlisted durable medical equipment/devices also require copies of catalog pages and medical justification to substantiate why a listed item is insufficient to meet the patient's medical needs.
(e)
The following items are not covered by the program:
(1)
Modification of automobiles/or other highway motor vehicles
(2)
Books or other items of a primarily educational nature
(3)
Air conditioners, air filters, or heaters
(4)
Food blenders
(5)
Reading lamps, or other lighting devices
(6)
Bicycles, tricycles, or exercise equipment, except as otherwise specified in this Chapter
(7)
Television sets
(8)
Orthopedic mattresses, recliners, rockers, seat lift chairs, or other furniture items
(9)
Waterbeds
(10)
Household items
(11)
Other items not generally used primarily for health care and which are regularly and primarily used by persons who do not have a specific medical need for them.
(f)
Authorization shall not be granted for medical equipment when a household or furniture item will adequately serve the patient's medical needs.
(g)
Authorization for durable medical equipment shall be limited to the lowest cost item that meets the patient's medical needs.
(h)
Authorization for durable medical equipment for skilled nursing facility/Level B or intermediate care facility/Level A inpatients may be approved as follows:
(1)
The equipment is necessary for the continuous care of the patient to meet the unusual medical needs of that patient. A patient may be considered to have unusual medical needs when a disease or medical condition is exacerbated by physical characteristics such as height, weight, and body build. Physical characteristics, in and of themselves, shall not constitute an unusual medical condition.
(2)
Canes, crutches, wheelchairs, wheelchair cushions, and walkers may be authorized only when the item must be custom made or modified to meet the unusual medical needs of the patient and the need is expected to be permanent. A custom wheelchair, either manual or power, is one which has been uniquely constructed or assembled to address a particular patient's individual medical needs for positioning, support and mobility.
(3)
Suction and positive pressure apparatus may be authorized only when the item will be continuously used by the patient or must be immediately available to the patient for one month or more.
(i)
Beneficiaries shall be responsible for appropriate use and care of durable medical equipment purchased for their use under the Medi-Cal program.
(j)
Rendering providers of durable medical equipment shall ensure that all devices and equipment are appropriate to meet the beneficiary's medical needs. If a piece of equipment or a device, when in actual use, fails to meet the beneficiary's needs, and the beneficiary's medical condition has not significantly changed since the device/equipment was dispensed, the rendering provider shall adjust or modify the equipment, as necessary, to meet the beneficiary's needs. Any equipment or device that cannot be adjusted or modified, shall be replaced by the rendering provider at no cost to the Medi-Cal program.
(k)
In addition to the requirements specified in subsections (a) through (j) above, authorization of the following shall be made in accordance with the criteria contained in the applicable chapter of the Manual of Criteria for Medi-Cal Authorization:
(1)
Antidecubitus Care (ADC) Support Surfaces--Chapter 13.1.
(2)
Osteogenesis Stimulator Devices to Accelerate the Healing of Selected Bone Fractures--Chapter 13.2.
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