N.H. Admin. Code § He-W 571.06

Current through Register No. 50, December 12, 2024

Section He-W 571.06 - Non-Covered Services

The following items shall not be covered:

(a) Items that do not meet the coverage criteria set forth in He-W 571.04;

(b) Specialty formulas when not needed for life-sustaining purposes, or as the sole source of nutrition, except as allowed under He-W 546;

(c) Common, over-the-counter, household and medicine-chest items that can be purchased without a prescription, including, but not limited to:

(1) Corn plasters and foot pads;

(2) Nursery supplies;

(3) Hand cleaners or sanitizers, such as Hygenall or Purell;

(4) Personal hygiene items including body lotions, toothbrushes, electric shavers, razors, and other hair removal devices and services;

(5) Thermometers;

(6) Odor barrier products;

(7) Toileting wipes, except as allowed by He-W 571.04(c) (18) above;

(8) First aid kits and supplies, including adhesive bandages and scissors;

(9) Mechanical heated water circulating pads and pumps, including hydrocollator heating units;

(10) Non-legend medications specified in accordance with He-W 570.05(d) ; and

(11) Nutritional supplements or formula as follows:

a. Dietary or food supplements;

b. Lactose-free foods or products that aid in lactose digestion;

c. Gluten-free products;

d. Low carbohydrate diets;

e. Weight-loss foods, formulas, and related products intended to aid in weight loss;

f. Normal grocery items, including over-the counter infant formulas;

g. Baby food and banked breast milk;

h. Grocery items that can be prepared in a blender and used with an enteral feeding system;

i. High protein powders and mixes;

j. Medical food products that:

1. Are prescribed without a diagnosis requiring such foods;

2. Used for convenience purposes;

3. Have no proven therapeutic benefit without an underlying disease, condition, or disorder;

4. Used as a substitute for acceptable standard dietary interventions; or

5. Are used exclusively for nutritional supplementation; and

k. Enteral nutrition when the recipient has food allergies or dental problems, but has the ability to meet his or her nutritional requirements through an alternative store-bought food source;

(d) Environmental modifications and controls, including:

(1) Wheelchair ramps;

(2) Tub rails;

(3) Space heaters and heat lamps;

(4) Air conditioners and fans;

(5) Air purifiers, including HEPA and vacuum filters;

(6) Vaporizers, humidifiers, and dehumidifiers;

(7) Aromatherapy;

(8) Stairway lifts and elevators;

(9) Lifting devices including electric patient lifts and hydraulics and ceiling tract lifting devices;

(10) Power generators; and

(11) Adaptive or computer switch toys;

(e) Items typically not used by the general public for a medical purpose, including:

(1) Furniture for non-mobility purposes including, but not limited to:

a. Corner seats;

b. Positioning chairs;

c. High chairs or other feeding type chairs;

d. All beds, except hospital beds as allowed by He-W 571.04(c) (20) c., and the pediatric specialty beds as allowed in He-W 571.04(c) (20) above;

e. Toddler beds, bassinets, portable cribs, or playpens; and

f. Massage and therapy tables and related equipment;

(2) Lumbar support cushions;

(3) Bedding, including electric or weighted blankets;

(4) Clothing items, including sportswear such as neoprene shorts;

(5) Hot Tubs, whirlpool equipment, aqua massagers, and sauna baths;

(6) Recreational, therapeutic, or exercise equipment including, but not limited to, bicycles, treadmills, weights, tables, mats, and swings; and

(7) Video, computer games, or computer applications intended for the purpose of exercise, recreation, education, or instruction;

(f) Items that contribute to or enhance fertility or procreation;

(g) Items typically used by the general public for preventing injury or ensuring safety, including:

(1) Car seats, except as allowed by He-W 571.04(d) (1) ;

(2) Helmets, including protective helmets used for sports and recreation, except as allowed by He-W 571.04(d) (2) ; and

(3) Pneumatic vests and lumbar supports;

(h) Disposable incontinence supplies for:

(1) Recipients younger than 3 years of age, except as allowed by He-W 546; and

(2) Recipients 21 years of age or older who do not meet the criteria set forth in He-W 571.04(c) (18) ;

(i) Bed wetting alarms;

(j) Sleep positioning wraps;

(k) Computer controlled and programmable lateral rotation therapy bed systems;

(l) Chewelry, and similar non-toxic jewelry, intended to be chewed;

(m) Magnets, crystals, gemstones, and similar non-evidenced based, experimental, or investigational healing items;

(n) Glucowatches;

(o) Auto-feeders;

(p) Automated medication reminder systems;

(q) Cast bags, such as Aquashield;

(r) Electric resuscitators and portable defibrillators;

(s) Bi-directional static progressive stretch devices, including, but not limited to, Joint Active Systems (JAS) splints;

(t) Service or therapy animals and related expenses;

(u) Apnea monitors, except when the criteria in He-W 571.04(c) (2) have been met;

(v) Prosthetic fingers, thumbs, and toes when not part of a covered prosthesis;

(w) Commercially available strollers;

(x) Wheelchairs requested within 24 months of the purchase of a customized stroller;

(y) The following accessories and options for wheelchairs, customized strollers, or other mobility devices:

(1) Wheelchair remote controls and attendant control switches;

(2) Power assist devices or equipment to modify a manual wheelchair into a power wheelchair;

(3) Air suspension systems;

(4) Power standers and seat lift mechanisms;

(5) Grade aids and anti-roll devices for manual wheelchairs;

(6) Wheelchairs with stair climbing options;

(7) Titanium framed and sport-type wheelchairs;

(8) Custom wheels for off-road use or for sport and recreational purposes;

(9) Any wheelchair accessory or option for purposes of allowing the recipient to perform leisure, social, or recreational activities;

(10) Lights, horns, mirror, baskets, pouches, backpacks, and similar accessories; and

(11) Back-up or spare wheelchairs for recipients who already have a wheelchair, power scooter, or customized stroller;

(z) Any back-up or spare equipment, with the exception of ventilators;

(aa) Replacement, repair, or modifications of an item when the need for which is the result of:

(1) Recipient abuse, misuse, or neglect;

(2) Failure to protect the item from the elements;

(3) Using the item inappropriately or contrary to its designed and intended use;

(4) Making improper repairs to the item, which would void any manufacturer's warranty;

(5) Loss of the item when basic safeguarding measures could have been instituted;

(6) Failure to maintain the item through proper routine maintenance by an authorized dealer; or

(7) Taking any action that would otherwise void the manufacturer's written warranty or is contrary to the manufacturer's recommendations for care, use, and maintenance;

(ab) Repairs, modifications, or adjustments to any rented item, including wheelchairs;

(ac) Repairs to recipient owned items, when the recipient does not meet the criteria for coverage of the item, or when such repairs, modifications, or adjustments are:

(1) Within the dispensing provider's or manufacturer's warranty; or

(2) Within one year of the purchase of the item or accessory, unless written documentation from the provider demonstrates a significant change in the recipient's medical condition that meets the coverage criteria for the item and the repair or modification is warranted;

(ad) Upgrades to or replacement of any functioning item that still meets the recipient's needs, but is being requested solely as a result of changing technology;

(ae) Items which are more costly than other available items which could be expected to provide the same, similar, or duplicate outcome;

(af) Any items that are primarily intended for use at a school, are part of a child's care plan at school, and could be obtained through the "Medicaid to Schools" program in accordance with He-M 1301, and the child and the child's school participate in the "Medicaid to Schools" program; and

(ag) Any items that are experimental, investigational, or non-FDA approved.

N.H. Admin. Code § He-W 571.06

(See Revision Note at chapter heading He-W 500); ss by #6158, eff 12-29-95, EXPIRED: 12-29-03

New. #8961, eff 8-20-07; amd by #8983, INTERIM, eff 9-21-07, EXPIRES: 3-19-08; amd by #9103, eff 3-12-08; amd by #9637, eff 1-16-10; amd by #9836, eff 12-18-10

Amended by Volume XXXVI Number 10, Filed March 10, 2016, Proposed by #11046, Effective 2/27/2016, Expires 2/27/2026.