This section describes coverage restrictions and limitations for Medical Supplies and DME. Changes in technology alone do not necessitate replacement or upgrades in equipment. If it is medically necessary for a member to exceed any of the listed limits, the prescribing provider must submit a request for PA and provide supporting medical documentation to establish the medical necessity. Unless otherwise specified, limits apply to all members twenty-one (21) years and older.
60.08-1Physician Provided SuppliesPhysicians may bill for those medical supplies needed to perform office procedures, which are above and beyond what is usually included in a normal office visit. Reimbursement is made on the basis of acquisition cost only and may not include any additional markup. Physicians must bill under Chapter II, Section 90, "Physician Services" of the MaineCare Benefits Manual.
A prescribing provider may not be reimbursed for both prescribing and supplying DME to the same member, unless the DME is otherwise unobtainable or the DME typically requires no maintenance or replacement during the period used by a member. If these circumstances do exist, reimbursement to the prescribing provider for also supplying DME shall be on the basis of the acquisition cost of the DME. The prescribing provider must maintain a copy of the invoice to support such claims. In addition, this policy shall also apply to any entity in which the provider has direct or indirect proprietary interest. All transactions are subject to State and Federal restrictions regarding self-referral.
DME providers may not bill for items delivered to a member in a prescribing provider's office.
60.08-2Orthotics and ProstheticsThe Department requires that orthotic or prosthetic services be provided by a licensed occupational therapist, a licensed physical therapist, prosthetist (American Board for Certification), or an accredited orthotist (Board for Orthotist Certification). PA is required for all custom molded orthotics and prosthetics regardless of price using evidence-based criteria and/or criteria based on national standards for evaluating what is considered medically necessary.
Providers shall warranty prosthetics for a period of one (1) year to assure proper fit of products purchased by the Department. The warranty will cover adjustments, repairs, and parts replacement associated with shrinkage, workmanship, etc.
60.08-3Augmentative and Alternative Communication DevicesMembers must trial augmentative and alternative communication devices before the Department will purchase or rent the devices. PA requests for augmentative and alternative communication devices shall include information documenting the trial period to determine the appropriateness and member utilization of the device.
60.08-4Specially Modified Foods and FormulasSpecially modified foods and formulas are covered when the member has inborn errors of metabolism.
60.08-5Orthopedic Shoes and Other Supportive Devices for FeetOrthopedic shoes and other supportive devices for the feet generally are not covered. However, shoes that are an integral part of a leg brace, and therapeutic shoes such as those furnished to diabetics, are covered. For members twenty-one (21) and older, these items are subject to the following limitations:
A. Items classified with HCPCS Level II codes as foot inserts, foot arch supports, shoe wedges or shoe heels are limited to two (2) units (meaning 2 items or 1 pair) per member per year.B. Items classified with HCPCS Level II codes as orthotic footwear, including orthopedic shoes or items classified as 'other orthopedic footwear', are limited to two (2) units (meaning 2 shoes or 1 pair) per year.C. Items classified with HCPCS Level II codes as shoe lifts are limited to eight (8) units per member per year (units are one (1) inch increments).D. Items classified with HCPCS Level II codes as diabetic footwear including diabetic shoes and fittings are limited to two (2) units per member per year (meaning 1 pair or 2 fittings). Modifications and inserts for diabetic shoes are limited to a combined total of six (6) units per member per rolling year.E. Items classified with HCPCS Level II codes as repositioning foot orthotics, excluding the words "abduction rotation bar" are limited to two (2) units (meaning 2 shoes or 1 pair) per year.60.08-6NebulizersNebulizers are limited to one per member every five (5) years for members twenty-one (21) and older.
60.08-7Incontinence SuppliesA. The monthly service limits for diapers and other disposable incontinence products for members twenty-one (21) years and older are as follows:1. Disposable briefs or pull ons are limited to eight (8) units per day for adults.2. Disposable personal pads, large sized disposable under pads, liners, shields, guards, and undergarments are limited to one hundred and fifty (150) units per thirty-six (36) day period for adults.3. Disposable non-sterile gloves are limited to 5 boxes (at 100 per box) or 500 gloves per member per 36-day period for adults. Effective January 1, 2019, gloves may be covered if the member requires a caregiver to change the briefs/pull-ups; this will require documentation by the prescribing provider in the member's medical record. If the member is able to change his/her own briefs/pull-ups, then gloves shall not be covered unless there is a specific medical need for gloves documented by the prescribing provider in the member's medical record.B. Incontinence supplies are not covered for children under five (5) years of age. If it is medically necessary for a child age four (4) years and younger to use incontinent supplies, then a DME provider may submit a request for PA which must include sufficient supporting medical documentation from the prescribing provider (i.e., specific medical exam records and supporting medical literature that shows that the member's medical condition causes incontinence that would not otherwise be normally expected in this age group) to establish the medical necessity and a bowel/bladder training program has failed. The request will be reviewed and decided by the Department or its Authorized Entity.C. Providers may provide up to a ninety (90) day supply. Members may refuse to accept more than a thirty-six (36) day supply.60.08-8Power Mobility Devices and Manual WheelchairsReimbursement for Power Mobility Devices (PMDs) requires PA whether or not the member is eligible for Medicare or other third party insurance. The PA criteria for PMDs are located on the MaineCare Health PAS Online Portal.
In the case of motorized wheelchair requests for Medicare/MaineCare dually eligible members, MaineCare will review the request and issue a PA decision and the allowable reimbursement rate if approved. The decision must be issued prior to the purchase of any Power Wheelchair (PWC) or Power Operated Vehicle (POV), and prior to the submission of any claims to Medicare. Any price changes for PWCs and POVs that have received Prior Authorization shall be treated in the same manner as all other price changes on prior authorized equipment.
A.LimitationsThe following limits apply to members twenty-one (21) years and older. Providers may submit documentation detailing the need to exceed the limits, and the Prior Authorization Unit will evaluate the need to exceed the limit.
1.Power Operated Vehicles: Members will be limited to one (1) Power Operated Vehicle (i.e. scooter) every three (3) years, and cannot upgrade to a power wheelchair until the three (3) years have lapsed. 2.Manual or Power Wheelchairs: Members will be limited to one (1) wheelchair (i.e. manual or Power Wheelchair) every five (5) years. B.General Requirements1.Manual or Power Wheelchairs: Members who meet the eligibility requirements for both a prosthetic device necessary to allow functional mobility and a power or manual wheelchair must choose between the prosthetic device and a wheelchair and must sign a letter exercising their choice. A wheelchair will be provided in the interim on a rental basis for those members choosing a prosthetic device. Members may seek a PA for a manual wheelchair in addition to a prosthesis if medically necessary.2. Regardless of the type, only one wheelchair at a time is reimbursable for each member.3. The primary purpose is not to allow the member to perform leisure or recreational activities.4. Reimbursement is allowed for amputee kits for standard wheelchairs in a NF or ICF- IID. Reimbursement for a wheelchair with right or lefthanded drive is allowed in case of arm amputee or paralysis.5. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.6. An exception to the requirement in Section 60.06-3(F) may be granted for a member who needs a wheelchair during the winter months but is unable to make the necessary home modifications due to the frozen conditions. The provider may not bill the Department for modifications or structural changes, as they are not a MaineCare-covered DME service.7. If a member-owned PMD meets coverage criteria, medically necessary replacement items, including but not limited to batteries, are covered.8. MaineCare does not consider inability to climb stairs a medically necessary indication for a PMD. A PMD is not considered medically necessary when the sole purpose is to elevate a person to eye level, to extend a wheelchair user's reach. In addition, inability to navigate rough terrain outside the home is not considered a medically necessary indication for a PMD.9. When requesting a PA for a PMD in a NF or other setting in which there is continuous supervision, the requesting provider must document the member's medical necessity to be independently mobile beyond what can be provided by staff in that setting.10. The Department will not approve equipment for purposes other than medical necessity.C.Evaluation and Documentation RequirementsThe following evaluation and documentation requirements must be met for the Department to approve PMDs:
1. The prescribing provider must perform a face-to-face evaluation with the member and shall refer the member to an experienced, licensed, MaineCare enrolled physical therapist (PT), occupational therapist (OT), or other provider who has specific training and experience in rehabilitation wheelchair evaluations. The prescribing provider shall provide medical documentation of the medical disease, syndrome, and/or functional impairment(s) that justify the medical necessity for the equipment and accessories;2. The PT/OT shall conduct an evaluation and provide a signed and dated report that includes equipment recommendations and identifies the medical disease, syndrome, and functional impairment(s) that justify the medical necessity for the equipment and accessories. The PT/OT shall have no financial affiliation with the medical equipment supplier. Accessories will be approved or denied based on MaineCare Criteria, as normal;3. The DME provider is required to retain the above documentation and a completed and signed home access report. The documentation should also include a statement indicating the member is able to transfer safely in and out of the PMD and has adequate trunk stability to safely ride in the PMD;4. The DME provider shall obtain a written prescription for the PMD, signed and dated by the prescribing provider who performed the face-to-face evaluation, within 45 days of the evaluation;5. The DME provider shall provide documentation to the Department, signed by the member, indicating that the member has been informed that the member will be limited to one (1) POV every three (3) years and cannot upgrade to a Power Wheelchair until the three (3) years have lapsed;6. The DME provider shall provide the Department an itemized list of all the medically necessary items and their cost, as well as the provider's usual and customary prices for the items;7. Documentation of the member's current height and weight are included in the member's medical record; and8. The member must have a letter from his or her physician stating that the member's condition is not expected to deteriorate significantly for three (3) years.60.08-9Hospital BedsThe following limits apply to members twenty-one (21) years and older:
A. Reimbursement will be limited to one (1) hospital bed every five (5) years.B. Reimbursement will be limited to one (1) standard mattress (to fit a hospital bed) every two (2) years.C. Trapeze bars attached to bed will be limited to two (2) per lifetime.D. Cushioned headrest will be limited to one (1) per year.60.08-10Other Limitations for Members Twenty-one (21) years of Age and OlderA. Mattress Pads to include Gel and Dry are limited to one (1) per year.B. Sitz bath is limited to one (1) per year.C. Canes are limited to one (1) per year.D. All walkers are limited to one (1) per year.E. All commodes are limited to two (2) per five (5) year period.F. Bath/shower chairs are limited to one (1) per five (5) year period.G. Bath/tub wall rail is limited to two (2) per three (3) year period.H. Raised toilet seat is limited to two (2) per three (3) year period.I. Cough stimulating device is limited to two (2) per year.J. All types of Intermittent Positive Pressure Breathing (IPPB) devices are limited to once per lifetime.K. Ultrasonic and Aerosol compressors with Small Volume Nebulizers (SVNEB) are limited to one (1) per year. L. Patient lift sling or seat is limited to one (1) per year.M. Hydraulic patient lift is limited to two (2) per lifetime.N. Transcutaneous Electrical Nerve Stimulator (TENS) units/treatment systems are limited to one (1) per year.O. Pneumonic Compression Devices (used to lymphedema and chronic venous insufficiency) are limited to one (1) device per year.P. Apnea monitors are limited to one (1) per year.Q. Respiratory suction pumps (home model, portable or stationary, electric), when purchased, are limited to one (1) per member every three (3) years; if paid for on a rental basis, the physician must document therapeutic benefit for renewal after ninety (90) days.60.08-11Continuous Positive Airway Pressure (CPAP) and Bi-level Positive Airway Pressure (Bi-PAP) DevicesThe Department requires sleep studies done within the three (3) years preceding the initial request to document the need for a CPAP and Bi-PAP device. All CPAP and Bi-PAP devices will be rented on a three- (3) month trial basis to determine appropriateness and member utilization. CPAP and Bi-PAP devices and supplies are limited to the following quantities for members under twenty-one (21):
A. Oral/nasal mask - one (1) per three (3) monthsB. Oral cushion - two (2) per one (1) monthC. Nasal pillow - two (2) per one (1) monthD. Full face mask - one (1) per three (3) monthsE. Facemask interface - one (1) per one (1) monthF. Nasal interface - two (2) per one (1) monthG. Head gear - one (1) per six (6) monthsH. Chin strap - one (1) per six (6) monthsI. Tubing - one (1) per one (1) monthJ. Tubing (with heating element) - one (1) per three (3) monthsK. Filter (disposable) - two (2) per one (1) monthL. Filter (non-disposable) - one (1) per six (6) monthsM. Oral interface - one (1) per three (3) monthsN. Exhalation port - one (1) per twelve (12) monthsO. Water chamber - one (1) per one (1) monthP. Humidifier - one (1) per five (5) yearsQ. C-PAP - one (1) per five (5) yearsR. Bi-PAP - one (1) per five (5) years60.08-12Hearing AidsHearing aids shall be purchased from a licensed audiologist or hearing aid dealer & fitter, utilizing a vendor contracted with the State of Maine's Division of Procurement Services. For more information, please visit the Division of Procurement Service's hearing aids contracts webpage. Members shall trial hearing aids for a trial period of at least thirty (30) days. Following the trial period, the audiologist or hearing aid dealer & fitter will provide written confirmation that the hearing aid meets the member's need and should be purchased.
A. Hearing aid accessories are not required to be purchased under contract.B. Hearing aids are subject to the following limitations: 1. Members twenty-one (21) years and older are limited to one (1) hearing aid or one (1) replacement pair every five (5) years.2. For members under the age of twenty-one (21), replacements are allowed once per year as medically necessary and as identified and referenced in the MaineCare Benefits Manual, Section 94.05-2.C. Six (6) replacement batteries are allowed per month.D. Back up or spare hearing aids and/or repairs to backup or spare hearing aids are not covered.60.08-13Dispense of Disposable Medical SuppliesThe Department shall authorize dispense of up to a ninety (90) day supply of items considered to be disposable medical supplies when medically necessary and all prior authorization approval has been obtained. The Department considers disposable medical supplies to include breast milk bags and incontinence, urological, ostomy, diabetic, and CPAP and Bi-PAP supplies.
60.08-14Breast Milk BagsBreast Milk Bags are limited to 120 units (bags) per member per rolling month.
60.08-15Automatic Blood Pressure MonitorsAutomatic Blood Pressure Monitors are limited to one unit per member per three (3) calendar years.
60.08-16Electric Breast Pumps and SuppliesEffective October 25, 2023, in accordance with 22 MRS 3174-KKK, electric breast pumps and supplies are covered without prior authorization or limitation when they are prescribed by a Qualified Provider.
C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-60, subsec. 144-101-II-60.08