016.27.20 Ark. Code R. 013

Current through Register Vol. 49, No. 10, October, 2024

Rule 016.27.20-013 - Hyperalimentation 1-19, Prosthetics 3-19, and State Plan Amendment 2020-0017

Section II Prosthetics

212.209(DME) Low-Profile Skin Level Gastrostomy Tube (Low-Profile Button) and Supplies for Beneficiaries of All Ages

The Arkansas Medicaid Program reimburses for the Low-Profile Skin Level Gastrostomy Tube (Low-Profile Button) and supplies for Medicaid-eligible beneficiaries of all ages. Prior authorization (PA) from DHS or its designated vendor is required.

When requesting prior authorization, form DMS-679A titled Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components, must be completed and sent, along with sufficient medical documentation. View or print contact information for how to submit the request.

The Low-Profile Kit is benefit-limited to two (2) per state fiscal year (SFY). The accessories, extension sets, and adapters are covered under the $250 medical supply benefit limit.

Benefit extensions will be considered on a case-by-case basis if proven to be medically necessary.

212.210DME Low-Profile Percutaneous Cecostomy Tube (Low-Profile Button) for Beneficiaries of All Ages

The Low-Profile Button for a Percutaneous Cecostomy Tube requires use of the following diagnosis codes. (View ICD codes.)

The Low-Profile Button for a Percutaneous Cecostomy Tube requires use of the following CPT codes:

44300

49442

49450

242.150Nutritional Formulae for Child Health Services (EPSDT)

Beneficiaries Under Twenty-one (21) Years of Age

The following list provides the enteral formula HCPCS procedure codes, any associated modifiers, code descriptions, and the formula covered for each HCPCS code. The code description lists the formula included in the category of nutrients.

The coverage listed is payable only if the service is prescribed as a result of a Child Health Services (EPSDT) screening/referral.

No prior authorization is required for nutritional formulae for EPSDT beneficiaries from age five (5) years through twenty (20) years.

Prior authorization is required for beneficiaries from birth through four (4) years. Use of modifier U7 in the following list will be necessary, as indicated.

To request prior authorization, providers should complete the Prescription & Prior Authorization Request for Medical Equipment Excluding Wheelchairs & Wheelchair Components (DMS-679A), attaching a copy of the EPSDT screening/referral as well as a prescription signed by the beneficiary's PCP. View or print form DMS-679A. View or print contact information for how to submit the request.

NOTE: The Women, Infant, and Children program (WIC) must be accessed before the Medicaid program for children from birth to five (5) years of age.

supplemental amounts of WIC-approved nutritional formula. The Medicaid nutritional formula list will be updated accordingly to continue compliance with the WIC Program in Arkansas. Changes will be reflected in the appropriate Medicaid provider manual.

For beneficiaries from birth through four (4) years of age, the use of modifier U8, as well as additional documentation, will be required when a non-WIC formula is prescribed, or WIC guidelines are not followed when prescribing special formula.

An EPSDT screening, which documents the PCP's medical rationale for prescribing a formula, as well as medical records documenting the beneficiary's failed trials of WIC formula, must be submitted for review. Flavor preferences for formulae will not be considered for medical necessity.

Exceptions to Use of Formulae

The following exceptions must be followed in order to use formulae listed in this section.

A. Nutramigen LIPIL - Sensitivity or allergy to milk or soy protein; chronic diarrhea, food allergies, Gl bleeds. Similac Advance must first have been tried.

B. Nutramigen Enflora LGG - Sensitivity or allergy to milk or soy protein; chronic diarrhea, food allergies, Gl bleeds. Similac Advance must first have been tried.

C. Pregestimil - Allergy to milk or soy protein; chronic diarrhea, short gut; cystic fibrosis; fat malabsorption due to Gl or liver disease.

D. Gerber Extensive HA - Allergy to milk or soy protein; severe malnutrition; chronic diarrhea; short bowel syndrome; known or suspected corn allergy. Similac Advance must first have been tried.

E. Alfamino Junior - Allergy to cow's milk, multiple food protein intolerance, and food allergy associated conditions: short bowel syndrome, gastroesophageal reflux disease (GERD), eosinophilic esophagitis, malabsorption, and other Gl disorders. Neocate Junior with Prebiotics is intended for children over the age of one (1) year.

F. Alfamino Infant - Allergy to cow's milk, multiple food protein intolerance, and food allergy associated conditions: short bowel syndrome, gastroesophageal reflux disease (GERD), eosinophilic esophagitis, malabsorption, and other Gl disorders. Similac Expert Care Alimentum, Nutramigen, or Pregestimil must first have been tried.

G. Portagen - Pancreatic insufficiency, bile acid deficiency, or lymphatic anomalies; biliary atresia; liver disease; chylothorax.

H. Similac PM 60/40 - Renal, cardiac, or other condition that requires lowered minerals.

I. Periflex Infant - PKU; Hyperphenylalaninemia; for infants and toddlers.

J. PKU Periflex Junior Plus - Hyperphenylalaninemia; for children and adults.

K. Gerber Good Start Premature 24- Preterm, low birth weight. Not intended for feeding low birth weight infants after they reach a weight of 3600 g (approximately eight (8) lbs.). Not approved for an infant previously on term formula or a term infant for increased calories.

L. Enfamil EnfaCare - Preterm infant transitional formula for use between premature formula and term formula. Not approved for an infant previously on term formula or a term infant for increased calories.

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under twenty-one (21) years of age. Modifier BO is used to bill for oral usage. When a second or third modifier is listed, that modifier must be used in conjunction with EP.

For beneficiaries from birth through four (4) years of age, the use of modifier U7, as well as additional documentation will be required when a non-WIC formula is prescribed, or WIC guidelines are not followed when prescribing special formula.

Modifiers in this section are indicated by the headings M1, M2, M3 and M4.

Nutritional Formulae for Child Health Services (EPSDT) Beneficiaries Under Twenty-one (21) Years of Age (Section 242.150 )

National Procedure Code	M1	M2	M3	M4	Description	Covered Formulae
B4149 B4149 B4149 B4149 Ages 0-4 Years requires PA B4150 B4150 B4150 B4150 Ages 0-4 Years requires PA	EP EP EP EP EP EP EP EP	BO U7 U7 BO U7 U7	BO BO		Enteral formula, blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4150 B4150 Ages 0-4 Years requires PA	EP EP	U1 U1	BO U7	BO	Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4152 B4152 B4152 B4152 Ages 0-4 Years requires PA	EP EP EP EP	BO U7 U7	BO		Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 Kcal/ml), with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4153 B4153 B4153 B4153 Ages 0-4 Years requires PA	EP EP EP EP	BO U7 U7	BO		Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4154 B4154 B4154 B4154 Ages 0-4 Years requires PA	EP EP EP EP	BO U7 U7	BO		Enteral formula, nutritionally complete, for special metabolic needs, includes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins, or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4155 B4155 Bill on paper (Indicate specific name of formula on claims.)	EP EP	BO ate			Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides), or combination, administered through an enteral feeding tube, 100 calories = 1 unit	MCT Oil Procel Protein Supplement Provimin
B4155 B4155 Ages 0-4 Years requires PA Bill on paper (Indicate specific name of formula on claims.)	EP EP	U7 ate	BO		Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides), or combination, administered through an enteral feeding tube, 100 calories = 1 unit	MCT Oil Procel Protein Supplement Provimin
B4155 B4155 B4155 B4155 Ages 0-4 Years requires PA	EP EP EP EP	U1 U1 U1 U1	BO U7 U7	BO	Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides), or combination, administered through an enteral feeding tube, 100 calories = 1 unit	SolCarb Scandical
B4155 B4155 B4155 B4155 Ages 0-4 Years requires PA	EP EP EP EP	U2 U2 U2 U2	BO U7 U7	BO	Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides), or combination, administered through an enteral feeding tube, 100 calories = 1 unit	Microlipid
B4155 B4155 B4155 B4155 Ages 0-4 Years requires PA	EP EP EP EP	U3 U3 U3 U3	BO U7 U7	BO	Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides), or combination, administered through an enteral feeding tube, 100 calories = 1 unit
B4158 B4158 B4158 B4158 Ages 0-4 Years requires PA	EP EP EP EP	BO U7 U7	BO		Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, or iron, administered through an enteral feeding tube, 100 calories = 1 unit
B4159 B4159 B4159 B4159 Ages 0-4 Years requires PA	EP EP EP EP	BO U7 U7	BO		Enteral formula, for pediatrics, nutritionally complete soy base with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, or iron, administered through an enteral feeding tube, 100 calories = 1 unit
B4159 B4159 B4159 B4159 Ages 0-4 Years requires PA	EP EP EP EP	BO U8 U8	U7 U7	BO	Enteral formula, for pediatrics, nutritionally complete soy base with intact nutrients, includes proteins, fats, carbohydrates, vitamins and minerals, may include fiber, or iron, administered through an enteral feeding tube, 100 calories = 1 unit
B4160 B4160 B4160 B4160 Ages 0-4 Years requires PA	EP EP EP EP	BO U7 U7	BO		Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4160 B4160 B4160 B4160 Ages 0-4 Years requires PA	EP EP EP EP	BO U8 U8	U7 U7	BO	Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4160 B4160 B4160 B4160 Ages 0-4 Years requires PA	EP EP EP EP	U1 U1 U1 U1	BO U7 U7	BO	Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4160 B4160 Ages 0-4 Years requires PA	EP EP	U1 U1	U8 U8	BO	Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4161 B4161 B4161 B4161 Ages 0-4 Years requires PA	EP EP EP EP	BO U7 U7	BO		Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4161 B4161 B4161 B4161 Ages 0-4 Years requires PA	EP EP EP EP	BO U7 U7	U8 U8	BO	Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4162 B4162 B4162 B4162 Ages 0-4 Years requires PA	EP EP EP EP	BO U7 U7	BO		Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4162 B4162 B4162 B4162 Ages 0-4 Years requires PA	EP EP EP EP	U1 U1 U1 U1	BO U7 U7	BO	Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

One (1) unit of service equals one-hundred (100) calories with a reimbursable maximum of thirty (30) units per day. Supplies furnished by prosthetics providers in conjunction with the nutritional formula must be billed to Medicaid with the prosthetics medical supply codes. These formulae are covered as nutritional supplements rather than as the sole source of nutrition.

NOTE: Beneficiaries who require enteral nutrition as the sole source of nutrition with the formulae being administered through a nasogastric, jejunostomy or gastrostomy tube should be referred to a hyperalimentation provider enrolled in the Medicaid Program.

Each claim should reflect a "from" and "through" date of service. The claims must not be filed until after the "through" date has elapsed. Claims may be submitted on either a weekly or a monthly basis.

242.153Low-Profile Skin Level Gastrostomy Tube (Low-Profile Button) and Low-Profile Percutaneous Cecostomy Tube and Supplies for Beneficiaries of All Ages

NOTE: When billing for the Low-Profile Percutaneous Cecostomy Tube or supplies, an additional third modifier UA will be required.

Modifiers in this section are indicated by the headings M1 and M2. Prior authorization requirements are shown under the heading PA.

National Procedure Code	M1	M2	PA	Description	Payment Method
B9998			Y	Low-Profile Kit	Purchase
B9998	NU	U1	Y	SECUR-LOK Extension Set with 2 Port 'Y' and Clamp 12" Length	Purchase
B9998	NU	U2	Y	SECUR-LOK Extension Set with 2 Port 'Y' and Clamp 24" Length	Purchase
B9998	NU	U3	Y	Bolus Extension Set with Single Port Clamp 12" Length	Purchase
B9998	NU	U4	Y	Bolus Extension Set with Single Port Clamp 24" Length	Purchase
B9998	NU	U5	Y	Bolus SECUR-LOK Extension Set Single Portw/Clamp 12" Length	Purchase
B9998	NU	U6	Y	Bolus SECUR-LOK Extension Set Single Port w/Clamp 24" Length	Purchase
B9998	NU	U7	Y	Microvasive Adapter	Purchase
B9998	NU	U8	Y	Microvasive Decompression Tube	Purchase

Section II Hyperalimentation

242.120Enteral (Sole Source) Formulae

The following pages provide the enteral formula HCPCS procedure codes, any associated modifiers, code descriptions, and the formula covered for each HCPCS code. The code description lists the formula included in the category of nutrients.

Modifiers in this section are indicated by the headings M1, M2, and M3.

Enteral formulae are divided into several categories. Each unit of service equals one-hundred (100) calories of formula. All supplies and equipment necessary to administer the nutrients in the beneficiary's place of residence, except the infusion pump and pump supply kit, are included in the unit description.

For beneficiaries from birth through four (4) years of age, the use of modifier U8, as well as additional documentation, will be required when a non-WIC formula is prescribed or WIC guidelines are not followed when prescribing special formula.

An EPSDT screening, which documents the PCP's medical rationale for prescribing a formula, as well as medical records documenting the beneficiary's failed trials of WIC formula, must be submitted for review. Flavor preference for formulae will not be considered for medical necessity.

A separate prior authorization must be obtained for the enteral infusion pump and the pump supply kit. The enteral infusion pump and the pump supply kit may be billed separately.

Exceptions to Use of Formula

The following exceptions must be followed in order to use formulae listed in this section.

A. Nutramigen LIPIL - Sensitivity or allergy to milk or soy protein; chronic diarrhea, food allergies, Gl bleeds. Similac Advance must first have been tried.

B. Nutramigen Enflora LGG - Sensitivity or allergy to milk or soy protein; chronic diarrhea, food allergies, Gl bleeds. Similac Advance must first have been tried.

C. Pregestimil - Allergy to milk or soy protein; chronic diarrhea, short gut; cystic fibrosis, fat malabsorption due to Gl, or liver disease.

D. Gerber Extensive HA - Allergy to milk or soy protein; severe malnutrition; chronic diarrhea; short bowel syndrome, known or suspected corn allergy. Similac Advance must first have been tried.

E. Alfamino Junior - Allergy to cow's milk, multiple food protein intolerance and food allergy associated conditions: short bowel syndrome, gastroesophageal reflux disease (GERD), eosinophilic esophagitis, malabsorption, and other Gl disorders. Neocate Junior with Prebiotics is intended for children over the age of one (1) year.

F. Alfamino Infant - Allergy to cow's milk, multiple food protein intolerance and food allergy associated conditions: short bowel syndrome, gastroesophageal reflux disease (GERD), eosinophilic esophagitis, malabsorption, and other Gl disorders. Similac Expert Care Alimentum, Nutramigen or Pregestimil must first have been tried.

G. Portagen - Pancreatic insufficiency, bile acid deficiency, or lymphatic anomalies; biliary atresia; liver disease; chylothorax.

H. Similac PM 60/40 - Renal, cardiac, or other condition that requires lowered minerals.

I. Periflex Infant - PKU; Hyperphenylalaninemia; for infants and toddlers.

J. PKU Periflex Junior Plus - Hyperphenylalaninemia; for children and adults.

K. Gerber Good Start Premature 24 - Preterm, low birth weight. Not intended for feeding low birth weight infants after they reach a weight of 3600g (approximately eight (8) lbs.). Not approved for an infant previously on term formula or a term infant for increased calories.

NOTE: The Women, Infant, and Children program (WIC) must be accessed before the Medicaid Program for children from birth to five (5) years of age.

The Arkansas Medicaid program mirrors coverage of approved WIC nutritional formulae. As stated in current policy, the WIC Program must be accessed first for Arkansas Medicaid beneficiaries aged zero (0) to five (5) years, prior to requesting supplemental amounts of WIC-approved nutritional formula. The Medicaid nutritional formula list will be updated accordingly to continue compliance with the WIC program in Arkansas. Changes will be reflected in the appropriate Medicaid provider manual.

HCPCS Code	M1	M2	M3	Description	Covered Formulae
B4149	U9			Enteral formula, blenderized natural foods with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4150	U9			Enteral formula, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4152	U9			Enteral formula, nutritionally complete, calorically dense (equal to or greater than 1.5 Kcal/ml), with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4153	U9			Enteral formula, nutritionally complete, hydrolyzed proteins (amino acids and peptide chain), includes fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4154	U9			Enteral formula, nutritionally complete, for special metabolic needs, includes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins, or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4155 Bill on Paper (Indicate specific name of formula on claims.)	U9			Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides), or combination, administered through an enteral feeding tube, 100 calories = 1 unit	MCT Oil Procel Protein Supplement Provimin
B4155	U9	U1		Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides), or combination, administered through an enteral feeding tube, 100 calories = 1 unit	Polycose Powder Scandical
B4155	U9	U2		Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides), or combination, administered through an enteral feeding tube, 100 calories = 1 unit	Microlipid
B4155	U9	U3		Enteral formula, nutritionally incomplete/modular nutrients, includes specific nutrients, carbohydrates (e.g., glucose polymers), proteins/amino acids (e.g., glutamine, arganine), fat (e.g., medium chain triglycerides), or combination, administered through an enteral feeding tube, 100 calories = 1 unit
B4158	U9			Enteral formula, for pediatrics, nutritionally complete with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, or iron, administered through an enteral feeding tube, 100 calories = 1 unit
B4159	U9			Enteral formula, for pediatrics, nutritionally complete soy base with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, or iron, administered through an enteral feeding tube, 100 calories = 1 unit
B4159 (Ages 0-4 Years)	U9	U8		Enteral formula, for pediatrics, nutritionally complete soy base with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, or iron, administered through an enteral feeding tube, 100 calories = 1 unit
B4160	U9			Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4160 (Ages 0-4 Years)	U9	U8		Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4160	U9	U1		Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4160 (Ages 0-4 Years)	U9	U1	U8	Enteral formula, for pediatrics, nutritionally complete calorically dense (equal to or greater than 0.7 Kcal/ml) with intact nutrients, includes proteins, fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4161	U9			Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4161 Ages 5 to 99 Years B4161 (Ages 0-4 Years)	U9 U9	U8		Enteral formula, for pediatrics, hydrolyzed/amino acids and peptide chain proteins, includes fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4162	U9			Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit
B4162	U9	U1		Enteral formula, for pediatrics, special metabolic needs for inherited disease of metabolism, includes fats, carbohydrates, vitamins, and minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit

ATTACHMENT 3.1-A

8. Private Duty Nursing Services

In addition, at least one (1) from each of the following conditions must be met:

1. Medications:

* Receiving medication via gastrostomy tube (G-tube)

* Have a Peripherally Inserted Central Catheter (PICC) line or central port

2. Feeding:

* Nutrition via a permanent access such as G-tube, Low-Profile Button, or Gastrojejunostomy tube (G-J tube). Feedings are either bolus or continuous.

* Parenteral nutrition (total parenteral nutrition)

Services are provided in the beneficiary's home, a Division of Developmental Disabilities (DDS) community provider facility, or a public school. (Home does not include an institution.) Prior authorization is required. Private duty nursing medical supplies are limited to a maximum reimbursement of $80.00 per month, per beneficiary. With substantiation, the maximum reimbursement may be extended.

ATTACHMENT 3.1-B

8. Private Duty Nursing to enhance the effectiveness of treatment for ventilator-dependent beneficiaries or non-

ventilator dependent tracheotomy beneficiaries.

Enrolled providers are Private Duty Nursing Agencies licensed by the Arkansas Department of Health. Services are provided by Registered Nurses or Licensed Practical Nurses licensed by the Arkansas State Board of Nursing.

Services are covered for Medicaid-eligible beneficiaries age twenty-one (21) and over when determined medically necessary and prescribed by a physician.

Beneficiaries twenty-one (21) and over to receive PDN Nursing Services must require constant supervision, visual assessment, and monitoring of both equipment and patient. In addition, the beneficiary must be:

A. Ventilator dependent (invasive) or

B. Have a functioning trach requiring:

1. suctioning;

2. oxygen supplementation; and

3. receiving Nebulizer treatments or require Cough Assist / in-exsufflator devices.

In addition, at least one (1) from each of the following conditions must be met:

1. Medications:

* Receiving medication via gastrostomy tube (G-tube)

* Have a Peripherally Inserted Central Catheter (PICC) line or central port

2. Feeding:

* Nutrition via a permanent access such as G-tube, Low-Profile Button, or Gastrojejunostomy tube (G-J tube).

Feedings are either bolus or continuous.

* Parenteral nutrition (total parenteral nutrition)

ATTACHMENT 4.19-B

7. Home Health Services

c. Medical Supplies, Equipment, and Appliances Suitable for Use in the Home

(12)Low-Profile Skin Level Gastrostomy Tube and Percutaneous Cecostomy Tube and Supplies

Effective for dates of service on or after September 1, 2000, reimbursement is based on the lesser of the provider's actual charge for the Low-Profile kits and accessories or the Title XIX (Medicaid) maximum. The agency's rates were set as of September 1, 2000 and are effective for services on or after that date. All rates are published on the agency's website. Except as otherwise noted in the plan, state developed fee schedule rates are the same for both governmental and private providers of DME services. The Title XIX (Medicaid) maximum for the kit and accessories is based on the manufacturer's list prices to the DME providers as of July 1, 2000 plus ten percent (10%). The State Agency will review the manufacturer's list prices annually and may adjust the Medicaid maximums if necessary. Arkansas Medicaid will reimburse providers for the kit and accessories as purchase only items.

Effective for dates of service on or after March 1, 2014, coverage of the Low-Profile for Percutaneous Cecostomy Tube will be reimbursed based on the above-mentioned methodology.

d. Physical Therapy Refer to Item 4.b.(19).

016.27.20 Ark. Code R. 013

Adopted by Arkansas Register Volume MMXX Number 18, Effective 12/1/2020