Section DHS 107.24 - Durable medical equipment and medical supplies(1) DEFINITION. In this section: (a) "Medical supplies" means disposable, consumable, expendable or nondurable medically necessary supplies which have a very limited life expectancy. Examples are plastic bed pans, catheters, electric pads, hypodermic needles, syringes, continence pads and oxygen administration circuits.(b) "Qualified health care professional" means any of the following:1. A physician or physician assistant licensed under subch. II of ch. 448, Stats.2. A physical therapist licensed under subch. III of ch. 448, Stats.3. An occupational therapist licensed under subch. VII of ch. 448, Stats.4. A chiropractor licensed under ch. 446, Stats.(2) COVERED SERVICES.(a)Prescription and provision.1. Durable medical equipment (DME) and medical supplies, excluding complex rehabilitation technology identified in subd. 2., are covered services only when prescribed by a physician and when provided by a certified physician, clinic, hospital outpatient department, nursing home, pharmacy, home health agency, therapist, orthotist, prosthetist, hearing instrument specialist or medical equipment vendor.2. Complex rehabilitation manual wheelchairs, power wheelchairs, and other seating components identified in the Wisconsin DME and medical supplies indices are covered services only when prescribed by a physician and when provided by a qualified complex rehabilitation technology supplier.(b)Items covered. Covered services are limited to items contained in the Wisconsin durable medical equipment (DME) and medical supplies indices. Items prescribed by a physician which are not contained in one of these indices or in the listing of non-covered services in sub. (5) require submittal of a DME additional request. Should the item be deemed covered, a prior authorization request may be required.(c)Categories of durable medical equipment. The following are categories of durable medical equipment covered by MA:1. Occupational therapy assistive or adaptive equipment. This is medical equipment used to assist a person with a disability to adapt to the environment or achieve independence in performing daily personal functions. Examples are adaptive hygiene equipment, adaptive positioning equipment and adaptive eating utensils.2. Orthopedic or corrective shoes. These are any shoes attached to a brace for prosthesis; mismatched shoes involving a difference of a full size or more; or shoes that are modified to take into account discrepancy in limb length or a rigid foot deformation. Arch supports are not considered a brace. Examples of orthopedic or corrective shoes are supinator and pronator shoes, surgical shoes for braces, and custom-molded shoes.3. Orthoses. These are devices which limit or assist motion of any segment of the human body. They are designed to stabilize a weakened part or correct a structural problem. Examples are arm braces and leg braces.4. Other home health care durable medical equipment. This is medical equipment used to increase the independence of a person with a disability or modify certain disabling conditions. Examples are patient lifts, hospital beds and traction equipment.5. Oxygen therapy equipment. This is medical equipment used for the administration of oxygen or medical formulas or to assist with respiratory functions. Examples are a nebulizer, a respirator and a liquid oxygen system.6. Physical therapy splinting or adaptive equipment. This is medical equipment used to assist a person with a disability to achieve independence in performing daily activities. Examples are splints and positioning equipment.7. Prostheses. These are devices which replace all or part of a body organ to prevent or correct a physical disability or malfunction. Examples are artificial arms, artificial legs and hearing aids.8. Wheelchairs. These are chairs mounted on wheels usually specially designed to accommodate individual disabilities and provide mobility. Examples are a standard weight wheelchair, a lightweight wheelchair and an electrically-powered wheelchair.9. Complex rehabilitation technology. These are items identified in the Wisconsin DME and medical supplies indices which are updated to comply with s. 49.45(9r) (a) 2, Stats.(d)Categories of medical supplies. Only approved items within the following generic categories of medical supplies are covered:1. Colostomy, urostomy and ileostomy appliances;2. Contraceptive supplies;3. Diabetic urine and blood testing supplies;5. Gastric feeding sets and supplies;6. Hearing aid or other assistive listening devices batteries;7. Incontinence supplies, catheters and irrigation apparatus;8. Parenteral-administered apparatus; and9. Tracheostomy and endotracheal care supplies.(3) SERVICES REQUIRING PRIOR AUTHORIZATION. All of the following services require prior authorization: (a) Purchase of all items indicated as requiring prior authorization in the Wisconsin DME and medical supplies indices, published periodically and distributed to appropriate providers by the department.(b) Repair or modification of an item which exceeds the department-established maximum reimbursement without prior authorization. Reimbursement parameters are published periodically in the DME and medical supplies provider handbook.(c) Purchase, rental, repair or modification of any item not contained in the current DME and medical supplies indices.(d) Purchase of items in excess of department-established frequencies or dollar limits outlined in the current Wisconsin DME and medical supplies indices.(e) The second and succeeding months of rental use, with the exception that all hearing aid or other assistive listening device rentals require prior authorization.(f) Purchase of any item which is not covered by Medicare, part b, when prescribed for a recipient who is also eligible for Medicare.(g) Any item required by a recipient in a nursing home which meets the requirements of sub. (4) (c).(h) Purchase or rental of a hearing aid or other assistive listening device in any of the following circumstances: 1. A request for prior authorization of a hearing aid or other ALD shall be reviewed only if the request consists of an otological report from the recipient's physician and an audiological report from an audiologist or hearing instrument specialist, is on forms designated by the department and contains all information requested by the department. A hearing instrument specialist may perform an audiological evaluation and a hearing aid evaluation to be included in the audiological report if these evaluations are prescribed by a physician who determines all of the following: a. The recipient is over the age of 21.b. The recipient is not cognitively or behaviorally impaired.c. The recipient has no special need which would necessitate either the diagnostic tools of an audiologist or a comprehensive evaluation requiring the expertise of an audiologist.2. After a new or replacement hearing aid or other ALD has been worn for a 30-day trial period, the recipient shall obtain a performance check from a certified audiologist, a certified hearing instrument specialist or at a certified speech and hearing center. The department shall provide reimbursement for the cost of the hearing aid or other ALD after the performance check has shown the hearing aid or ALD to be satisfactory, or 45 days has elapsed with no response from the recipient.3. Special modifications other than those listed in the MA speech and hearing provider handbook shall require prior authorization.4. Provision of services in excess of the life expectancies of equipment enumerated in the MA speech and hearing provider handbook require prior authorization, except for hearing aid or other ALD batteries and repair services.(i) A request for prior authorization of complex rehabilitation manual wheelchairs, complex rehabilitation power wheelchairs, and other complex rehabilitation seating components shall be reviewed only if the request consists of all of the following:1. Documentation of a complex rehabilitative technology clinical evaluation performed by a qualified health care professional that includes all of the following: a. A detailed description of the qualified health care professional's assessment as outlined in the provider handbook including identification of the specific complex rehabilitation technology items requested.b. A detailed description of the medical necessity as defined in ss. DHS 101.03 (96m) and 107.02 (3) (e), for each complex rehabilitation technology request.c. The qualified health care professional's signature and date of completion.2. Documentation stating that a direct, on-premises complex rehabilitation technology evaluation was performed by a qualified complex rehabilitation technology professional that includes all of the following: a. A detailed description of the recipient's current durable medical equipment and requested complex rehabilitation technology items, the projected lifespan of both, the accessibility of the setting in which the requested items are to be used, the recipient's applicable methods of transportation, and an analysis of at least one comparable alternative to each requested item including an explanation of why the alternative does not meet the recipient's needs.b. A statement asserting that the qualified complex rehabilitation technology professional will provide appropriate training to the recipient and will maintain adequate documentation of the training provided.c. A statement indicating presence at the recipient's complex rehabilitation technology clinical evaluation or other coordination with the qualified health care provider conducting the complex rehabilitation clinical evaluation to assist in selection of the most appropriate complex rehabilitation technology item.d. The qualified complex rehabilitation technology professional's signature and date of completion.3. A signed statement from each qualified health care professional, who performs the complex rehabilitation technology clinical evaluation, providing documentation of a complex rehabilitation technology clinical evaluation in subd. 1. indicating he or she does not have a financial relationship with the complex rehabilitation technology supplier providing the requested items.(j) A request for prior authorization of all complex rehabilitation technology not included in par. (i) shall be reviewed only if the request complies with MA policy and procedures as described in MA provider handbooks and bulletins and includes a detailed description of the medical necessity, as defined in s. DHS 101.03 (96m), of the complex rehabilitation technology requested. Note: For more information on prior authorization, see s. DHS 107.02 (3).
(4) OTHER LIMITATIONS. (a) Payment for medical supplies ordered for a patient in a medical institution is considered part of the institution's cost and may not be billed directly to the program by a provider. Durable medical equipment and medical supplies provided to a hospital inpatient to take home on the date of discharge are reimbursed as part of the inpatient hospital services. No recipient may be held responsible for charges or services in excess of MA coverage under this paragraph.(b) Prescriptions shall be provided in accordance with s. DHS 107.02 (2m) (b) and may not be filled more than one year from the date the medical equipment or supply is ordered.(c) The services covered under this section are not covered for recipients who are nursing home residents except for: 1. Oxygen. Prescriptions for oxygen shall provide the required amount of oxygen flow in liters;2. Durable medical equipment which is personalized in nature or custom-made for a recipient and is to be used by the recipient on an individual basis for hygienic or other reasons. These items are orthoses, prostheses including hearing aids or other assistive listening devices, orthopedic or corrective shoes, special adaptive positioning wheelchairs and electric wheelchairs. Coverage of a special adaptive positioning wheelchair or electric wheelchair shall be justified by the diagnosis and prognosis and the occupational or vocational activities of the resident recipient; and3. A wheelchair prescribed by a physician if the wheelchair will contribute towards the rehabilitation of the resident recipient through maximizing his or her potential for independence, and if the recipient has a long-term or permanent disability and the wheelchair requested constitutes basic and necessary health care for the recipient consistent with a plan of health care, or the recipient is about to transfer from a nursing home to an alternate and more independent setting.(d) The provider shall weigh the costs and benefits of the equipment and supplies when considering purchase or rental of DME and medical supplies. Note: The program's listing of covered services and the maximum allowable reimbursement schedules are based on basic necessity. Although the program does not intend to exclude any manufacturer of equipment, reimbursement is based on the cost-benefit of equipment when comparable equipment is marketed at less cost. Several medical supply items are reimbursed according to generic pricing.
(e) The department may determine whether an item is to be rented or purchased on behalf of a recipient. In most cases equipment shall be purchased; however, in those cases where short-term use only is needed or the recipient's prognosis is poor, only rental of equipment shall be authorized.(f) Orthopedic or corrective shoes or foot orthoses shall be provided only for postsurgery conditions, gross deformities, or when attached to a brace or bar. These conditions shall be described in the prior authorization request.(g) Provision of hearing aid accessories shall be limited as follows: 1. For recipients under age 18: 3 earmolds per hearing aid, 2 single cords per hearing aid and 2 Y-cords per recipient per year;2. For recipients over age 18: one earmold per hearing aid, one single cord per hearing aid and one Y-cord per recipient per year; and3. For all recipients: one harness, one contralateral routing of signals (CROS) fitting, one new receiver per hearing aid and one bone-conduction receiver with headband per recipient per year.(h) If a prior authorization request is approved, the person shall be eligible for MA reimbursement for the service on the date the final ear mold is taken.(i) Reimbursement for complex rehabilitation technology is limited to qualified complex rehabilitation technology suppliers.(j) The cost of mailing or delivery, such as shipping and handling charges and fees, of diagnostic tools or equipment needed to assess, diagnose, repair or setup medical supplies, hearing aids, cochlear implants, or other equipment cannot be billed to the recipient.(5) NON-COVERED SERVICES. The following services are not covered services: (a) Foot orthoses or orthopedic or corrective shoes for the following conditions:1. Flattened arches, regardless of the underlying pathology;2. Incomplete dislocation or subluxation metatarsalgia with no associated deformities;3. Arthritis with no associated deformities; and4. Hypoallergenic conditions;(b) Services denied by both Medicare and MA for lack of medical necessity.(c) Items which are not primarily medical in nature, such as dehumidifiers and air conditioners;(d) Items which are not appropriate for home usage, such as oscillating beds;(e) Items which are not generally accepted by the medical profession as being therapeutically effective, such as a heat and massage foam cushion pad;(f) Items which are for comfort and convenience, such as cushion lift power seats or elevators, or luxury features which do not contribute to the improvement of the recipient's medical condition;(g) Repair, maintenance or modification of rented durable medical equipment;(h) Delivery or set-up charges for equipment as a separate service;(i) Fitting, adapting, adjusting or modifying a prosthetic or orthotic device or corrective or orthopedic shoes as a separate service;(j) All repairs of a hearing aid or other assistive listening device performed by a dealer within 12 months after the purchase of the hearing aid or other assistive listening device. These are included in the purchase payment and are not separately reimbursable;(k) Hearing aid or other assistive listening device batteries which are provided in excess of the guidelines enumerated in the MA speech and hearing provider handbook; (l) Items that are provided for the purpose of enhancing the prospects of fertility in males or females;(m) Impotence devices, including but not limited to penile prostheses;(n) Testicular prosthesis;(p) Infant formula and enteral nutritional products except as allowed under s. DHS 107.10 (2) (c).Wis. Admin. Code Department of Health Services § DHS 107.24
Cr. Register, February, 1986, No. 362, eff. 3-1-86; emerg. r. and recr. (3) (h) 1. and 2., eff. 7-1-89; am. (2) (d) 6., (3) (e), (h) 4., (4) (c) 2., (5) (j) and (k), r. and recr. (3) (h) (intro.), 1. and 2. and (4) (g), cr. (4) (h), Register, May, 1990, No. 413, eff. 6-1-90; r. and recr. (4) (a), Register, September, 1991, No. 429, eff. 10-1-91; am. (5) (j) to (k), cr. (5) (L) to (p), Register, January, 1997, No. 493, eff. 2-1-97; correction in (4) (b) made under s. 13.93(2m) (b) 7, Stats., Register February 2002 No. 554; CR 03-033: am. (2) (a), (3) (h) 1. (intro.), 2., and (5) (j) Register December 2003 No. 576, eff. 1-1-04.Amended by, CR 20-012: renum. (1) to (1) (intro.) and am., cr. (1) (b), am. (2) (a), cr. (2) (a) 2., am. (2) (c) 1., 4., 6., cr. (2) (c) 9., am. (3) (intro.), (a) to (g), (h) 1. to 3., cr. (3) (i), (j), (4) (i), am. (5) (b) Register October 2021 No. 790, eff. 11-1-21; correction in (3) (g) made under s. 35.17, Stats., Register October 2021 No. 790; CR 20-039: am. (2) (c) 1., 4. to 6. Register October 2021 No. 790, eff. 11-1-21; merger of (2) (c) 1., 4., 6. treatments by CR 20-012 and CR 20-039 made under s. 13.92(4) (bm), Stats., Register October 2021 No. 790, eff. 11/1/2021Amended by, correction in (2) (a) 1. made under s. 35.17, Stats., Register November 2021 No. 792, eff. 1/1/2022Amended by, correction in (2) (a) 1. made under s. 35.17, Stats., Register December 2021, No. 792; CR 22-043: Register May 2023 No. 809, eff. 6/1/2023