N.H. Admin. Code § He-W 571.04

Current through Register No. 36, September 5, 2024

Section He-W 571.04 - Covered Services

(a) The purchase of medical supplies, except incontinence supplies, for continuous use or on an as-needed basis, shall not require prior authorization and shall be covered when prescribed, except as follows:

(1) Specialty formulas and food products shall only be covered in accordance with (b) (3) a. and b. below;

(2) Enteral formulas and supplies shall only be covered in accordance with (b) (3) c. below; and

(3) Medical supplies that are listed as non-covered services in He-W 571.06 shall not be covered.

(b) The following items shall be covered when prescribed and supported by an LMN:

(1) The purchase of, or repairs to, prosthetic devices, including prosthetic fingers, thumbs, and toes when they are part of a covered prostheses except as prohibited in He-W 571.06(v) ;

(2) The purchase of, or repairs to, orthotic devices;

(3) The purchase of the following medical supplies:

a. Specialty formulas prescribed for life-sustaining purposes;

b. Specialty formulas and food products prescribed for metabolic diseases described in RSA 415:6-c;

c. Enteral formulas and supplies when oral feeds are contraindicated; and

d. Disposable incontinence products for recipients between 3 and 20 years of age;

(4) The purchase of one standard manual breast pump per pregnancy;

(5) Bed cradle when necessary to prevent contact with the bed covering for conditions such as burns, decubitis, diabetic ulcers, and gout; and

(6) Except as specified in (c) (5) below, repairs to a purchased, non-rental, wheelchair when such repairs do not exceed a total of $800 within a given state fiscal year, which begins July 1st and ends June 30th.

(c) Unless a requested item is considered non-covered as specified in He-W 571.06, all items that are not otherwise indicated as covered in (a) -(b) above, shall be covered when prescribed, supported by an LMN, and prior authorized in accordance with He-W 571.05, and as follows:

(1) Infant home apnea monitors shall be covered when at least one of the following criteria is met:

a. Within the past 30 days from the date the completed PA request is submitted to the department, the infant has experienced an ALTE; and

b. The infant has one or more of the following conditions:

1. Tracheostomy or anatomic abnormalities of the face, tongue, jaw, or airway that make the infant vulnerable to airway compromise;

2. Neurologic or metabolic disorders affecting respiratory control;

3. Chronic lung disease, such as bronchopulmonary dysplasia, which requires supplemental oxygen (O₂), continuous positive airway pressure, or mechanical ventilation;

4. Apnea of prematurity;

5. Bradycardia on caffeine, theophylline, or similar agents;

6. Diagnosis of pertussis, with positive laboratory results;

7. Diagnosis of gastroesophageal reflux disease (GERD) that results in apnea of at least 20 seconds, bradycardia, or O₂ saturation; or

8. Discharged home on a schedule of weaning narcotics;

(2) A PA approved for an infant home apnea monitor shall be issued as follows:

a. The initial approval shall be valid for 3 months;

b. PA requests for additional coverage beyond the initial 3-month period shall be granted until the infant is ALTE-free for 2 months or until the child reaches 12 months of age, whichever comes first; and

c. PA requests for coverage after the infant reaches 12 months of age shall be granted when supported by physician documentation recommending the continuation of monitoring based on the child's condition;

(3) An external insulin pump for the treatment of insulin-dependent diabetes (Type 1) shall be limited to one pump per recipient every 4 years or more frequently if technology evolves so that the pump can no longer be used, and shall be approved when the following criteria are met:

a. The recipient has received 3 or more daily insulin injections for at least 6 consecutive months;

b. The recipient has self-monitored his or her own blood sugar at least 4 times per day for the past 2 consecutive months;

c. The recipient and the recipient's family demonstrate to the recipient's physician or to the recipient's diabetic educator the ability to carbohydrate count using insulin-to-carbohydrate ratios as well as insulin correction factors;

d. The recipient has a documented history of recurrent hypoglycemia with wide fluctuations in blood glucose, despite recipient compliance;

e. The recipient has dawn phenomenon with fasting sugars frequently exceeding 200 mg/dl;

f. The recipient has a history of severe glycemic excursions; and

g. An endocrinologist, or a physician with similar skills and training as an endocrinologist in the management of external insulin pumps, prescribes the pump and is involved with the medical care of the recipient;

(4) The purchase of a wig shall be covered with approval being subject to RSA 415:18-d;

(5) The purchase of any wheelchair or wheelchair accessory, as well as all repairs and modifications made to purchased wheelchairs that exceed the $800 limit set forth in (b) (6) above, shall be covered when the following criteria are met:

a. The need for a wheelchair, accessory, repair, or modification has been evaluated by a physical therapist (PT) or occupational therapist (OT), in consultation with the ordering physician;

b. The recipient has a condition for which there is a disease process, injury, or disability:

1. That would contraindicate weight bearing or ambulation; and

2. Where there is a decrease in neuromuscular function that prevents the recipient from being able to ambulate without assistance;

c. When the PA request is for a power wheelchair, the recipient:

1. Is unable to propel a manual wheelchair because of a disease process, injury, or disability; and

2. Is able to safely and independently operate a power wheelchair;

d. The wheelchair is not solely for the convenience of the recipient, or the recipient's family or caregivers;

e. The recipient does not already have another mobility device that meets the recipient's mobility needs; and

f. When the PA request is to replace an existing wheelchair, the following criteria are met:

1. It is not possible to repair or modify the existing wheelchair or replacement of the existing wheelchair is found to be the least costly alternative;

2. The current wheelchair no longer meets the recipient's mobility needs; and

3. The request is not being made solely as a result of changing technology, age of the current wheelchair, or a desire for a new wheelchair;

(6) Customized strollers shall be covered only for recipients who:

a. Are non-ambulatory;

b. Meet the criteria for wheelchair approval as set forth in (5) above;

c. Do not already have a wheelchair or customized stroller, and are not expected to be prescribed a wheelchair within 24 months; and

d. Have mobility needs that will not be met by a commercially available stroller with adaptations;

(7) Gait trainers shall be covered only for recipients who:

a. Are able to stand upright with assistance and have some lower-extremity and trunk strength to be supported in the gait trainer;

b. Are not able to ambulate independently due to a condition such as, but not limited to, neuromuscular or congenital disorders, including acquired skeletal abnormalities;

c. Do not have lower-extremity contractures that would preclude ambulation, and have adequate range of motion to support mobility;

d. Have alignment of the lower extremities such that the foot and ankle can tolerate a standing or upright position as well as reciprocal movement;

e. Do not have complete paralysis of the lower extremities;

f. Have demonstrated improved mobility, ambulation, function, or physiologic symptoms, or have maintained status with the use of the selected gait trainer, and are able to follow a home therapy program incorporating the use of the gait trainer, as documented by a clinical program or home trial with the requested gait trainer; and

g. Have a written home therapy plan outlining the use of the requested gait trainer and for whom there is a caretaker who can appropriately supervise use of the gait trainer;

(8) Standers shall be covered only for recipients who:

a. Do not already have a stander or gait trainer;

b. Are unable to stand or ambulate independently due to a condition such as, but not limited to, a neuromuscular or congenital disorder, including acquired skeletal abnormalities;

c. Are at high risk for lower extremity contractures that cannot be appropriately managed by other treatment modalities, such as stretching, active therapy, and home programs;

d. Have an alignment of the lower extremities such that they can tolerate a standing or upright position;

e. Do not have complete paralysis of the lower extremities;

f. Do not have orthostatic hypotension, postural tachycardia syndrome, osteogenesis imperfecta, osteoporosis or other brittle bone diseases, or hip and knee flexion contractures of more than 20°;

g. Have demonstrated improved mobility, function, and physiologic symptoms, or have maintained status with the use of the requested stander, when other alternatives have failed, and are able to follow a home standing program incorporating the use of the stander, as documented by clinical standing program or home trial with the requested stander;

h. Are unable to stand or ambulate with caregiver assistance or an ambulatory assistive device at sufficient duration or distance to achieve a medical benefit;

i. Have a home therapy plan outlining the use of the requested stander; and

j. Have a request for a stander using code E0642, and are able to self-propel the stander;

(9) Cranial remolding helmets shall be covered when the following criteria are met:

a. The recipient is at least 3 months of age, but not older than 18 months of age;

b. The recipient has marked asymmetry that has not been substantially improved following conservative therapy of at least 2 months duration with cranial repositioning therapy and/or physical therapy; and

c. The asymmetry of the cranial base is documented by one of the following:

1. Skull base asymmetry of at least 6 mm right or left discrepancy, measured subnasally to the tragus, which is the cartilaginous projection of the auricle at the front of the ear; or

2. Cranial vault asymmetry of at least 10 mm right or left discrepancy, measured obliquely from the supraorbital point to the parietooccipital scalp at the midpoint of maximal convexity and from the supraorbital point to the parietooccipital scalp at the midpoint of the flattened area, or a ratio of these 2 measurements is greater than 1:1;

(10) A continuous positive air pressure (CPAP) machine to treat obstructive sleep apnea (OSA) in recipients up to the age of 21 shall be covered when all of the following criteria are met:

a. Adenotonsillectomy is contraindicated, delayed, or unsuccessful in relieving symptoms of OSA;

b. There is an OSA diagnosis established by polysomnography (PSG) performed by a medicare certified sleep study center, or a children's hospital; and

c. The recipient is 7 years of age or older and weighs 40 pounds or more;

(11) A CPAP machine to treat OSA in a recipient 21 years of age or older shall be covered when all of the following criteria are met:

a. The recipient has a diagnosis of OSA established by PSG performed by a medicare certified sleep study center; and

b. At least one of the following clinical criteria has been met:

1. The apnea-hypopnea index (AHI), which assesses the severity of sleep apnea, is moderate to severe, which is defined as 15 or more events per hour; or

2. The AHI is from 5 to 14 events per hour with documentation of symptoms of daytime sleepiness, impaired cognition, mood disorders, or insomnia that impairs the recipient's ability to carry out activities of daily living, and one of the following conditions is met:

(i) A diagnosis of hypertension, ischemic heart disease, or a history of stroke; or

(ii) More than 20 episodes of O₂ desaturation, measuring less than 85%, or any one episode of O₂ desaturation, measuring less than 70%, during a full-night sleep study;

(12) A CPAP machine covered in accordance with (10) or (11) above shall be prior authorized as follows:

a. The initial authorization shall be limited to a 2-month trial rental of the CPAP machine to ensure the recipient uses the machine daily and will receive a sufficient benefit from use of the machine;

b. The recipient's daily use shall be documented by a compliance report indicating that the recipient is gaining sufficient benefit from the CPAP machine, as evidenced by a downloaded recording from the machine showing usage of a daily minimum of 4 hours per night;

c. Following the 2-month trial period, if the recipient demonstrates daily use as described in b. above during the 2-month trial rental period, the requesting dispensing provider may submit a subsequent PA request, which shall include the documentation described in b. above, for the purchase of the CPAP machine;

d. If the recipient does not use the machine as required in b. above during the trial period, but the non-compliance is correctable, such as by adjusting the fit of the mask, the requesting dispensing provider may submit a subsequent PA request for an additional rental period; and

e. Following the trial rental period, if it is demonstrated that the CPAP machine is not providing a sufficient benefit to the recipient, and the failure is not due to non-compliance, abuse, or neglect, the requesting dispensing provider may submit a PA request for a bi-level positive airway pressure (BiPAP) machine;

(13) The department shall approve a request for a BiPAP machine when it has been determined, in accordance with (12) above, that a CPAP machine is not effective in treating the recipient's OSA;

(14) A BiPAP machine shall be covered as follows:

a. The initial authorization shall be limited to a 2-month trial rental of the BiPAP machine to ensure the recipient uses the machine daily and will receive a sufficient benefit from use of the machine;

b. The recipient's daily use shall be documented by a compliance report indicating that the recipient is gaining sufficient benefit from the BiPAP machine, as evidenced by a downloaded recording from the machine showing usage of a daily minimum of 4 hours per night; and

c. Following the 2-month trial period, if the recipient demonstrates daily use during the trial rental period as required in b. above, the requesting item provider may submit a subsequent PA request, which shall include the documentation described in b. above, for the purchase of the BiPAP machine;

(15) High-frequency chest compression (HFCC) devices shall be covered when the following criteria are met:

a. The recipient is at least 2 years of age at the time the device is being used;

b. The recipient has a documented need of airway clearance;

c. The recipient has one of the following documented diagnoses:

1. Cystic fibrosis;

2. Chronic bronchiectasis that:

(i) Is characterized by a daily productive cough that has been confirmed by high resolution, spiral, or a standard CT scan;

(ii) Lasts for at least 6 consecutive months; or

(iii) Results in exacerbation, at least 2 times in a one year period, that requires antibiotic therapy; or

3. Chronic neuromuscular disorder affecting the ability to cough or clear respiratory secretions with a prior history of pneumonia or other significant worsening of pulmonary function, which exists when at least 2 of the following criteria are met:

(i) Forced expiration capacity (FEC) of 80% predicted;

(ii) Forced vital capacity (FVC) of less than 50% predicted;

(iii) Small airway score (FEP 25-75%) decrease in one year of 25% or more;

(iv) Pattern of annual or more hospitalizations for acute pulmonary exacerbations; or

(v) Demonstration of reduction of pulmonary function while on steroids for a year;

d. The recipient's physician provides documentation demonstrating that standard treatments have failed to adequately mobilize retained secretions, as indicated by one of the following:

1. Other airway clearance therapies, including chest physical therapy or the use of a flutter device, cannot be performed at least twice daily, or as would be appropriate for the recipient's age, because:

(i) There are no available parental or partner resources to perform chest physical therapy;

(ii) The caregiver is physically or mentally incapable of performing chest physical therapy at the required frequency; or

(iii) There are 2 or more individuals with cystic fibrosis, chronic bronchiectasis, or chronic neuromuscular disorder in the same household; or

2. There is a significant deterioration of the recipient's clinical conditions, as described in c.3. above; and

e. The recipient is under the care of a pulmonologist;

(16) A HFCC device covered in accordance with (15) above shall be prior authorized as follows:

a. The initial authorization shall be limited to a 2-month trial rental of the HFCC device to ensure the recipient uses the device daily and will receive a sufficient benefit from use of the device;

b. The recipient's daily use and sufficient benefit from usage during the 2-month trial rental period shall be documented by:

1. A report completed by a pulmonologist documenting the recipient's comfort, tolerance, and willingness to use the device;

2. A report completed by a pulmonologist demonstrating that the recipient has sufficiently benefited from the use of the HFCC device as evidenced by clinical indications, including:

(i) Improvement in forced expiratory volume (FEV1); or

(ii) A reduction in the number of hospitalizations per year;

3. A statement signed by the pulmonologist, which may be part of the report in 2. above, stating that the recipient has sufficiently benefited from the use of the HFCC device, and that the pulmonologist recommends continued usage of the HFCC device; and

4. A usage meter report generated by the dispensing provider documenting usage at least 67% of the prescribed time;

c. Following the 2-month trial rental period specified in a. above, the requesting dispensing provider may submit a prior authorization request for an additional rental period, not to exceed one year, by submitting a prior authorization request along with documentation demonstrating the recipient's use as described in b. above;

d. A request for an additional rental period or to purchase the device through a rent-to-own arrangement, submitted in accordance with c. above, shall be approved by the department when the clinical evidence of the recipient's use and sufficient benefit supports continued use of the HFCC device; and

e. Approvals shall be limited to only one HFCC device and one vest per size per family;

(17) Oximeters shall be covered when the recipient has been assessed by his or her physician or pulmonary specialist to determine if supplemental O₂ is required, and either:

a. The recipient has been on supplemental O₂ and an oximeter is requested to determine if he or she can be weaned from the supplemental O₂; or

b. The recipient is receiving supplemental O₂ and is experiencing widely fluctuating O₂ saturation levels and an oximeter is required to assist in determining the cause, frequency, and duration of the fluctuation to properly determine the O₂ flow rate;

(18) Disposable incontinence supplies, including chux underpads, incontinence briefs, pull-ups, diapers, pads or liners, and gloves and toileting wipes used for this condition, for recipients 21 years of age or older shall be covered in accordance with the following:

a. The PA shall be approved for a period of one year if the recipient's type of incontinence is:

1. Secondary to a disease process or injury to the bladder, which results in irreversible loss of control of the urinary bladder and/or rectal sphincter;

2. Secondary to an injury to the brain or spinal cord;

3. Secondary to a disease or condition that causes incontinence; or

4. Attributed to a profound cognitive disability or progressive neurological disorder, such as severe intellectual disability, dementia, or tardive dyskinesia, that results in an inability to achieve continence through bladder training;

b. The PA shall be approved for a period of 6-months if the recipient's type of incontinence is:

1. Secondary to a surgical procedure, such as prostatectomy, resulting in temporary urinary incontinence; or

2. Secondary to an injury to the bladder and/or urinary sphincter, including nerve injury and detrusor muscle instability, resulting in temporary urinary incontinence; and

c. The following quantity limits shall apply, unless the prior authorization request specifies and medically justifies a greater quantity:

1. Disposable chux underpads shall be limited to a total of 3 per day, up to 93 per month, except that if package sizes necessitate dispensing a greater monthly quantity, the monthly quantity shall not exceed 105 per month;

2. Incontinence briefs, pull-ups, and diapers shall be limited to a total of 6 per day, up to 186 per month, except as follows:

(i) If package sizes necessitate dispensing a monthly quantity which is greater than 186, the monthly quantity shall not exceed 216 per month; and

(ii) The dispensing provider shall dispense the fewest number of packages that result in a quantity as close as possible to the 186 limit without going under, for example, if a package size is 10 diapers per package, then 19 packages equaling 190 diapers shall be dispensed, not 20 nor 21 packages; and

3. Pads and liners used to line undergarments shall be limited to a total of 3 per day, up to 93 per month, except as follows:

(i) If package sizes necessitate dispensing a monthly quantity which is greater than 93, the monthly quantity shall not exceed 144 per month; and

(ii) The dispensing provider shall dispense the fewest number of packages that result in a quantity as close as possible to the 93 limit without going under, for example, if a package size is 16 liners per package, then 6 packages equaling 96 liners shall be dispensed, not 17, 18, nor 19 packages;

(19) Functional electric stimulation (FES), which is used to enable a recipient with spinal cord injury to ambulate, shall be covered when the recipient meets all of the following:

a. Has intact lower motor units, L1 and below, both muscle and peripheral nerve;

b. Can bear weight on upper and lower extremities to maintain an upright posture independently;

c. Demonstrates brisk muscle contraction in response to neuromuscular electrical stimulation through a trial use of the equipment by the recipient's physical therapist, and has sensory perception of electrical stimulation sufficient for muscle contraction;

d. Is motivated and has the cognitive ability to use such devices for walking;

e. Can transfer independently and stand for at least 3 continuous minutes;

f. Possesses hand and finger function to manipulate the controls;

g. Is at least 6-months post-recovery of spinal cord injury and restorative surgery;

h. Does not have hip or knee degenerative disease and has no history of long bone fracture secondary to osteoporosis; and

i. Has successfully completed a training program, which consists of at least 32 physical therapy sessions with the device over a 3-month period;

(20) Pediatric specialty beds shall be covered for infants and children up to the age of 12, as follows:

a. The recipient has one or more of the following diagnoses:

1. Traumatic brain injury;

2. Moderate or severe cerebral palsy;

3. Seizure disorder with daily seizure activity, characterized by loss of consciousness or lack of awareness to surroundings;

4. Pervasive developmental disorder;

5. Psychiatric, neurological, or metabolic diagnosis with documented risk of self-injury; or

6. Severe behavioral disorder;

b. The recipient has cognitive and communication impairment;

c. There is documentation of medical necessity that includes at least one of the following:

1. Daily seizure activity as described in a.3. above;

2. Uncontrolled perpetual involuntary movement related to a medical diagnosis; or

3. Self-injurious behavior, such as head banging, where a helmet was tried and was not successful at reducing the self-injurious behavior;

d. There is evidence of a safety risk that includes at least one of the following:

1. The recipient demonstrates unsafe mobility that will put the recipient at risk for serious injury, not just a possibility of injury, such as climbing out of bed;

2. The recipient has balance problems or vertigo; or

3. The recipient has history of injury that has occurred prior to the request;

e. There is documented use of more cost effective alternatives for which the outcomes were unsuccessful, such as:

1. Positional aids and side rails with padding around the regular bed;

2. Alternative bedding, such as moving the mattress to the floor with surrounding padding;

3. Management of seizure disorder;

4. Pharmacotherapy;

5. Helmet for head protection;

6. Behavioral therapy;

7. Environmental assessment and removal of safety hazards and use of appropriate child protective devices, such as on the door knob or use of a baby gate to prevent the child from leaving the room; or

8. Use of portable monitoring devices, such as a baby monitor to listen in on the child's activities; and

f. The LMN includes the following:

1. The recipient's medical, psychiatric, neurological, metabolic, and behavioral diagnosis;

2. The recipient's needs that are a result of the diagnosis that shows the medical need for the specialty bed;

3. The specific name, type, and bed model that addresses each of the recipient's needs with specific requirements such as full safety rails, height required for safety, or the necessity of articulation to raise the head or feet of the child to feed, medicate, or provide mobility;

4. Documentation as to how the recipient's current bed or crib or modifications to the bedroom fail to address the clinical need and which states whether the recipient has the capacity to climb;

5. Current and previous treatment modalities, including an explanation why these modalities were not successful;

6. Assessment of cognitive function including developmental age equivalent for motor function, cognitive function, and habilitation potential; and

7. Detailed history of safety issues including incidence and resulting injury;

(21) Coverage of other items that are not specifically listed elsewhere in this rule, such as those listed below, shall be based on the National Coverage Determinations (NCD) criteria published in the Medicare Coverage Database (MCD) at the time of the coverage determination, as found at http://www.cms.gov/medicare-coverage-database/ [File Link Not Available], including:

a. Pressure-reducing surfaces;

b. Enteral feeding pumps;

c. Hospital beds and accessories;

d. External infusion pumps, with the exception of insulin pumps, which shall be subject to the criteria set forth in He-W 571.04(c) (3) above;

e. Negative pressure wound therapy pumps;

f. Pneumatic compression devices;

g. Hoyer type lifts and other patient lift transfer systems;

h. Transcutaneous electrical nerve stimulators (TENS);

i. Trapeze bars;

j. Osteogenesis stimulators;

k. Parenteral nutrition pumps;

l. Suction machines;

m. Airway clearance devices, such as inexsufflators;

n. Voice activated home glucose monitors;

o. Seat lift mechanisms that are not part of a wheelchair;

p. Continuous passive motion machines; and

q. Oxygen compressors and humidification devices; and

(22) For items that are not specifically listed elsewhere in this rule and are also not listed in the MCD, the department shall review the recipient's medical information and shall cover the item when the department determines that coverage of the item:

a. Is clinically appropriate in terms of type, frequency of use, extent, site, and duration, and consistent with the established diagnosis or treatment of the recipient's illness, injury, disease, or its symptoms as determined by a review of the coverage criteria set forth in the New Hampshire or New England commercial insurance coverage as listed in He-W 530.05(b) (32) b.;

b. Is not primarily for the convenience of the recipient or the recipient's family, caregiver, or health care provider;

c. Is no more costly than other items or services that would produce equivalent diagnostic, therapeutic, or treatment results as related to the recipients' illness, injury, disease, or its symptoms;

d. Is not experimental, investigative, cosmetic, or duplicative in nature; and

e. Is allowable under Medicaid and does not otherwise conflict with the New Hampshire Medicaid State Plan.

(d) All items billed with any Healthcare Common Procedure Coding System (HCPCS) miscellaneous procedure code shall be covered when prescribed, supported by an LMN, and prior authorized in accordance with He-W 571.05, and as follows:

(1) Customized car seats shall be covered for recipients who have a neuromotor diagnosis and whose needs cannot be met by a commercially available car seat with minor adaptations that do not reduce the effectiveness or safety of the car seat nor make the manufacturer's warranty null and void; and

(2) Protective helmets for recipients with drop seizures or severe head-banding disorders.

N.H. Admin. Code § He-W 571.04

(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 (deletion of former paragraphs (b)-(f) and renumbering remaining paragraph (a) as (a)-(f)); amd by #9103, eff 3-12-08

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