HEALTH CARE AUTHORITY

(Washington Apple Health)

(1) The federal government considers durable medical equipment (DME) and related supplies, complex rehabilitation technology (CRT), prosthetics, orthotics, and medical supplies ((as)) to be optional services under the medicaid program, except when prescribed as an integral part of an approved plan of treatment under the home health program or required under the early and periodic screening, diagnosis and treatment (EPSDT) program. The ((department)) medicaid agency may reduce or eliminate coverage for optional services, consistent with legislative appropriations.

(2) The ((department)) agency covers the DME and related supplies, CRT, prosthetics, orthotics, and related services including modifications, accessories, and repairs, and medical supplies listed in this chapter, according to ((department)) agency rules and subject to the limitations and requirements in this chapter.

(3) The ((department)) agency pays for DME and related supplies, CRT, prosthetics, orthotics, and related services including modifications, accessories, and repairs, and medical supplies when ((it is)) they are:

(a) Covered;

(b) Within the scope of the client's medical program (see WAC ((388-501-0060 and 388-501-0065)) 182-501-0060 and 182-501-0065);

(c) Medically necessary, as defined in WAC ((388-500-0005)) 182-500-0070;

(d) Prescribed by a physician, advanced registered nurse practitioner (ARNP), naturopathic physicians, or physician assistant certified (PAC) within the scope of his or her licensure, except for dual eligible medicare/medicaid clients when medicare is the primary payer and the ((department)) agency is being billed for a co-pay and/or deductible only;

(e) Authorized, as required within this chapter, chapters ((388-501 and 388-502)) 182-501 and 182-502 WAC, and the ((department's)) agency's published billing instructions and ((numbered memoranda)) provider notices;

(f) Billed according to this chapter, chapters ((388-501 and 388-502)) 182-501 and 182-502 WAC, and the ((department's)) agency's published billing instructions and ((numbered memorandum)) provider notices; and

(g) Provided and used within accepted medical or physical medicine community standards of practice.

(4) The ((department)) agency requires prior authorization for covered DME and related supplies, CRT, prosthetics, orthotics, medical supplies, and related services when the clinical criteria set forth in this chapter are not met, including the criteria associated with the expedited prior authorization process.

(a) The ((department)) agency evaluates requests requiring prior authorization on a case-by-case basis to determine medical necessity, according to the process found in WAC ((388-501-0165)) 182-501-0165.

(b) Refer to WAC ((388-543-7000, 388-543-7001, and 388-543-7003)) 182-543-7000, 182-543-7100, and 182-543-7300 for specific details regarding authorization.

(5) The ((department)) agency bases its determination about which DME and related supplies, CRT, prosthetics, orthotics, medical supplies, and related services require prior authorization (PA) or expedited prior authorization (EPA) on utilization criteria (see WAC ((388-543-7100)) 182-543-7100 for PA and WAC ((388-543-7300)) 182-543-7300 for EPA). The ((department)) agency considers all of the following when establishing utilization criteria:

(a) ((High)) Cost;

(b) The potential for utilization abuse;

(c) A narrow therapeutic indication; and

(d) Safety.

(6) The ((department)) agency evaluates a request for any ((DME)) item listed as noncovered in this chapter under the provisions of WAC ((388-501-0160)) 182-501-0160. When early and periodic screening, diagnosis and treatment (EPSDT) applies, the ((department)) agency evaluates a noncovered service, equipment, or supply according to the process in WAC ((388-501-0165)) 182-501-0165 to determine if it is medically necessary, safe, effective, and not experimental (see WAC ((388-543-0100)) 182-543-0100 for EPSDT rules).

(7) The ((department)) agency may terminate a provider's participation with the ((department)) agency according to WAC ((388-502-0030 and 388-502-0040)) 182-502-0030 and 182-502-0040.

(8) The ((department)) agency evaluates a request for a service that is in a covered category, but has been determined to be experimental or investigational under the provisions of WAC ((388-501-0165)) 182-501-0165.

The following definitions and abbreviations and those found in chapter 182-500 WAC ((388-500-0005)) apply to this chapter.

"By-report (BR)" ((A method of payment in which the department determines the amount it will pay for a service when the rate for that service is not included in the department's published fee schedules. The provider must submit a report which describes the nature, extent, time, effort and/or equipment necessary to deliver the service.))  - See WAC 182-500-0015.

"Date of delivery" - The date the client actually took physical possession of an item or equipment.

"Digitized speech" (also referred to as devices with whole message speech output) - Words or phrases that have been recorded by an individual other than the speech generating device (SGD) user for playback upon command of the SGD user.

"Disposable supplies" - Supplies which may be used once, or more than once, but are time limited.

"Durable medical equipment (DME)" - Equipment that:

(1) Can withstand repeated use;

(2) Is primarily and customarily used to serve a medical purpose;

(3) Generally is not useful to a person in the absence of illness or injury; and

(4) Is appropriate for use in the client's place of residence.

"EPSDT" - See WAC ((388-500-0005)) 182-500-0030.

"Expedited prior authorization (EPA)" - ((The process for obtaining authorization for selected health care services in which providers use a set of numeric codes to indicate to the department which acceptable indications, conditions, or department-defined criteria are applicable to a particular request for authorization. EPA is a form of prior authorization.)) See WAC 182-500-0030.

"Fee-for-service (FFS)" - ((The general payment method the department uses to pay for covered medical services provided to clients, except those services covered under the department's prepaid managed care programs.)) See WAC 182-500-0035.

"Health care common procedure coding system (HCPCS)" - A coding system established by the Health Care Financing Administration (HCFA) to define services and procedures. HCFA is now known as the Centers for Medicare and Medicaid Services (CMS).

"Home" - For the purposes of this chapter, means location, other than hospital or skilled nursing facility where the client receives care.

"House wheelchair" - A skilled nursing facility wheelchair that is included in the skilled nursing facility's per-patient-day rate under chapter 74.46 RCW.

"Limitation extension" - A client-specific authorization by the ((department)) agency for additional covered services beyond the set amount allowed under ((department)) agency rules. See WAC ((388-501-0169)) 182-501-0169.

"Manual wheelchair" - See "wheelchair - Manual."

"Medical supplies" - Supplies that are:

(1) Primarily and customarily used to service a medical purpose; and

(2) Generally not useful to a person in the absence of illness or injury.

"Medically necessary" - See WAC ((388-500-0005)) 182-500-0070.

"National provider indicator (NPI)" - ((A federal system for uniquely identifying all providers of health care services, supplies, and equipment.)) See WAC 182-500-0075.

"Other durable medical equipment (other DME)" - All durable medical equipment, excluding wheelchairs and wheelchair-related items.

"Orthotic device" or "orthotic" - A corrective or supportive device that:

(1) Prevents or corrects physical deformity or malfunction; or

(2) Supports a weak or deformed portion of the body.

"Personal or comfort item" - An item or service which primarily serves the comfort or convenience of the client or caregiver.

"Power-drive wheelchair" - See "wheelchair - Power."

"Pricing cluster" - A group of manufacturers' list prices for brands/models of DME, medical supplies and nondurable medical equipment that the ((department)) agency considers when calculating the reimbursement rate for a procedure code that does not have a fee established by medicare.

"Prior authorization" - ((The requirement that a provider must request, on behalf of a client and when required by rule, the department's approval to render a health care service or write a prescription in advance of the client receiving the health care service or prescribed drug, device, or drug-related supply. The department's approval is based on medical necessity. Receipt of prior authorization does not guarantee payment. Expedited prior authorization and limitation extension are types of prior authorization.)) See WAC 182-500-0085.

"Prosthetic device" or "prosthetic" - ((A replacement, corrective, or supportive device prescribed by a physician or other licensed practitioner of the healing arts, within the scope of his or her practice as defined by state law, to:

(3) Support a weak or deformed portion of the body.)) See WAC 182-500-0085.

"Resource-based relative value scale (RBRVS)" - A scale that measures the relative value of a medical service or intervention, based on the amount of physician resources involved.

"Reusable supplies" - Supplies which are to be used more than once.

"Scooter" - A federally approved, motor-powered vehicle that:

(1) Has a seat on a long platform;

(2) Moves on either three or four wheels;

(3) Is controlled by a steering handle; and

(4) Can be independently driven by a client.

"Specialty bed" - A pressure reducing support surface, such as foam, air, water, or gel mattress or overlay.

"Speech generating device (SGD)" - An electronic device or system that compensates for the loss or impairment of a speech function due to a congenital condition, an acquired disability, or a progressive neurological disease. The term includes only that equipment used for the purpose of communication. Formerly known as "augmentative communication device (ACD)."

"Synthesized speech" - Is a technology that translates a user's input into device-generated speech using algorithms representing linguistic rules, unlike prerecorded messages of digitized speech. A SGD that has synthesized speech is not limited to prerecorded messages but rather can independently create messages as communication needs dictate.

"Three- or four-wheeled scooter" - A three- or four-wheeled vehicle meeting the definition of scooter (see "scooter") and which has the following minimum features:

(1) Rear drive;

(2) A twenty-four volt system;

(3) Electronic or dynamic braking;

(4) A high to low speed setting; and

(5) Tires designed for indoor/outdoor use.

"Trendelenburg position" - A position in which the patient is lying on his or her back on a plane inclined thirty to forty degrees. This position makes the pelvis higher than the head, with the knees flexed and the legs and feet hanging down over the edge of the plane.

"Usual and customary charge" - ((The amount the provider typically charges to fifty percent or more of his or her patients who are not medical assistance clients.)) See WAC 182-500-0110.

"Warranty-period" - A guarantee or assurance, according to manufacturers' or provider's guidelines, of set duration from the date of purchase.

"Wheelchair - Manual" - A federally approved, nonmotorized wheelchair that is capable of being independently propelled and fits one of the following categories:

(1) Standard:

(a) Usually is not capable of being modified;

(b) Accommodates a person weighing up to two hundred fifty pounds; and

(c) Has a warranty period of at least one year.

(2) Lightweight:

(a) Composed of lightweight materials;

(b) Capable of being modified;

(c) Accommodates a person weighing up to two hundred fifty pounds; and

(d) Usually has a warranty period of at least three years.

(3) High-strength lightweight:

(a) Is usually made of a composite material;

(b) Is capable of being modified;

(c) Accommodates a person weighing up to two hundred fifty pounds;

(d) Has an extended warranty period of over three years; and

(e) Accommodates the very active person.

(4) Hemi:

(a) Has a seat-to-floor height lower than eighteen inches to enable an adult to propel the wheelchair with one or both feet; and

(b) Is identified by its manufacturer as "Hemi" type with specific model numbers that include the "Hemi" description.

(5) Pediatric: Has a narrower seat and shorter depth more suited to pediatric patients, usually adaptable to modifications for a growing child.

(6) Recliner: Has an adjustable, reclining back to facilitate weight shifts and provide support to the upper body and head.

(7) Tilt-in-space: Has a positioning system, which allows both the seat and back to tilt to a specified angle to reduce shear or allow for unassisted pressure releases.

(8) Heavy duty:

(a) Specifically manufactured to support a person weighing up to three hundred pounds; or

(b) Accommodating a seat width of up to twenty-two inches wide (not to be confused with custom manufactured wheelchairs).

(9) Rigid: Is of ultra-lightweight material with a rigid (nonfolding) frame.

(10) Custom heavy duty:

(a) Specifically manufactured to support a person weighing over three hundred pounds; or

(b) Accommodates a seat width of over twenty-two inches wide (not to be confused with custom manufactured wheelchairs).

(11) Custom manufactured specially built:

(a) Ordered for a specific client from custom measurements; and

(b) Is assembled primarily at the manufacturer's factory.

"Wheelchair - Power" - A federally approved, motorized wheelchair that can be independently driven by a client and fits one of the following categories:

(1) Custom power adaptable to:

(a) Alternative driving controls; and

(b) Power recline and tilt-in-space systems.

(2) Noncustom power: Does not need special positioning or controls and has a standard frame.

(3) Pediatric: Has a narrower seat and shorter depth that is more suited to pediatric patients. Pediatric wheelchairs are usually adaptable to modifications for a growing child.

(1) ((Durable medical equipment (DME) and related services, prosthetics and orthotics, medical supplies and related services are available to clients who are eligible for services under one of the following medical assistance programs:

(2))) Refer to the table in WAC 182-501-0060 to see which Washington apple health (WAH) programs include DME and related services, complex rehabilitation technology (CRT), prosthetics and orthotics, medical supplies and related services in their benefit package.

(3) Clients who are eligible for services under medicare and medicaid (medically needy program-qualified medicare beneficiaries) are eligible for DME and related services, CRT, prosthetics and orthotics, medical supplies and related services.

(((3))) (4) Clients who are enrolled in a ((department contracted)) agency-contracted managed care organization (MCO) must arrange for DME and related services, prosthetics and orthotics, medical supplies and related services directly through his or her ((department-contracted)) agency-contracted MCO. The ((department)) agency does not pay for medical equipment and/or services provided to a client who is enrolled in a ((department-contracted)) agency-contracted MCO, but chose not to use one of the MCO's participating providers.

(((4))) (5) For clients who reside in a skilled nursing facility, see WAC ((388-543-5700)) 182-543-5700.

(1) The medicaid agency pays qualified providers for durable medical equipment (DME) and related supplies, complex rehabilitation technology (CRT), prosthetics, orthotics, medical supplies, repairs, and related services on a fee-for-service basis as follows:

(a) DME providers who are enrolled with medicare for DME and related repair services;

(b) Qualified CRT suppliers who are enrolled with medicare for DME and related repair services;

(c) Medical equipment dealers who are enrolled with medicare, pharmacies who are enrolled with medicare, and home health agencies under their national provider indicator (NPI) for medical supplies;

(((c))) (d) Prosthetics and orthotics providers who are licensed by the Washington state department of health in prosthetics and orthotics. Medical equipment dealers and pharmacies that do not require state licensure to provide selected prosthetics and orthotics may be paid for those selected prosthetics and orthotics only as long as the medical equipment dealers and pharmacies meet the medicare enrollment requirement;

(((d))) (e) Physicians who provide medical equipment and supplies in the office. The agency may pay separately for medical supplies, subject to the provisions in the ((department's)) agency's resource-based relative value scale fee schedule; and

(((e))) (f) Out-of-state orthotics and prosthetics providers who meet their state regulations.

(2) Providers and suppliers of ((durable medical equipment ())DME(())) and related supplies, CRT, prosthetics, orthotics, medical supplies and related items must:

(a) Meet the general provider requirements in chapter 182-502 WAC;

(b) Have the proper business license and be certified, licensed and/or bonded if required, to perform the services billed to the ((department)) agency;

(c) Have a valid prescription;

(i) To be valid, a prescription must:

(A) Be written on the agency's Prescription Form (HCA 13-794). The agency's electronic forms are available online at: ((http://hrsa.dshs.wa.gov/mpforms.shtml)) http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx;

(B) Be written by a physician, advanced registered nurse practitioner (ARNP), naturopathic physician, or physician's assistant certified (PAC);

(C) Be written, signed (including the prescriber's credentials), and dated by the prescriber on the same day and before delivery of the supply, equipment, or device. Prescriptions must not be back-dated;

(D) Be no older than one year from the date the prescriber signs the prescription; and

(E) State the specific item or service requested, diagnosis, estimated length of need (weeks, months, or years), and quantity.

(ii) For dual eligible medicare/medicaid clients when medicare is the primary payer and the ((department)) agency is being billed for the co-pay and/or deductible only, subsection (2)(a) of this section does not apply.

(d) Provide instructions for use of equipment;

(e) Furnish only new equipment to clients that includes full manufacturer and dealer warranties. See WAC 182-543-2250(3);

(f) Furnish documentation of proof of delivery, upon agency request (see WAC 182-543-2200); and

(g) Bill the agency using only the allowed procedure codes listed in the agency's published DME and related supplies, prosthetics and orthotics, medical supplies and related items ((medicaid provider guides)) billing instructions.

(1) An interested party may request the ((department)) medicaid agency to include new equipment/supplies in the ((department's)) agency's durable medical equipment (DME) and related supplies, complex rehabilitation technology (CRT), prosthetics, orthotics, medical supplies and related services billing instructions.

(2) The request should include credible evidence, including but not limited to:

(a) Manufacturer's literature;

(b) Manufacturer's pricing;

(c) Clinical research/case studies (included FDA approval, if required);

(d) Proof of certification from the Centers for Medicare and Medicaid Services (CMS), if applicable; and

(e) Any additional information the requester feels would aid the ((department)) agency in its determination.

(3) Requests should be sent to the DME Program Management Unit, P.O. Box 45505, Olympia WA 98504-5506.

(1) When a provider delivers an item directly to the client or the client's authorized representative, the provider must furnish the proof of delivery when the ((department)) medicaid agency requests that information. All of the following apply:

(a) The ((department)) agency requires a delivery slip as proof of delivery((, and it)). The proof of delivery slip must:

(i) Be signed and dated by the client or the client's authorized representative (the date of signature must be the date the item was received by the client);

(ii) Include the client's name and a detailed description of the item(s) delivered, including the quantity and brand name; and

(iii) For durable medical equipment (DME) and complex rehabilitation technology (CRT) that may require future repairs, include the serial number.

(b) When the provider or supplier submits a claim for payment to the ((department)) agency, the date of service on the claim must be one of the following:

(i) For a one-time delivery, the date the item was received by the client or the client's authorized representative; or

(ii) For nondurable medical supplies for which the ((department)) agency has established a monthly maximum, on or after the date the item was received by the client or the client's authorized representative.

(2) When a provider uses a delivery/shipping service to deliver items which are not fitted to the client, the provider must furnish proof of delivery that the client received the equipment and/or supply, when the ((department)) agency requests that information.

(a) If the provider uses a delivery/shipping service, the tracking slip is the proof of delivery. The tracking slip must include:

(i) The client's name or a reference to the client's package(s);

(ii) The delivery service package identification number; and

(iii) The delivery address.

(b) If the provider/supplier does the delivering, the delivery slip is the proof of delivery. The delivery slip must include:

(i) The client's name;

(ii) The shipping service package identification number;

(iii) The quantity, detailed description(s), and brand name(s) of the items being shipped; and

(iv) For DME and CRT that may require future repairs, the serial number.

(c) When billing the ((department)) agency:

(i) Use the shipping date as the date of service on the claim if the provider uses a delivery/shipping service; or

(ii) Use the actual date of delivery as the date of service on the claim if the provider/supplier does the delivery.

(3) A provider must not use a delivery/shipping service to deliver items which must be fitted to the client.

(4) Providers must obtain prior authorization when required before delivering the item to the client. The item must be delivered to the client before the provider bills the ((department)) agency.

(5) The ((department)) agency does not pay for DME and related supplies, CRT, prosthetics and orthotics, medical supplies and related items furnished to the ((department's)) agency's clients when:

(a) The medical professional who provides medical justification to the ((department)) agency for the item provided to the client is an employee of, has a contract with, or has any financial relationship with the provider of the item; or

(b) The medical professional who performs a client evaluation is an employee of, has a contract with, or has any financial relationship with a provider of DME and related supplies, CRT, prosthetics and orthotics, medical supplies, and related items.

(1) The ((department)) medicaid agency bases its decision to rent or purchase durable medical equipment (DME) on the length of time the client needs the equipment.

(2) A provider must not bill the ((department)) agency for the rental or purchase of equipment supplied to the provider at no cost by suppliers/manufacturers.

(3) The ((department)) agency purchases new DME equipment and complex rehabilitation technology (CRT) only.

(a) A new DME item that is placed with a client initially as a rental item is considered a new item by the ((department)) agency at the time of purchase.

(b) A used DME item that is placed with a client initially as a rental item must be replaced by the supplier with a new item prior to purchase by the ((department)) agency.

(4) The ((department)) agency requires a dispensing provider to ensure the DME rented to a client is:

(a) In good working order; and

(b) Comparable to equipment the provider rents to individuals with similar medical equipment needs who are either private pay or who have other third-party coverage.

(5) The ((department's)) agency's minimum rental period for covered DME is one day.

(6) The ((department)) agency authorizes rental equipment for a specific period of time. The provider must request authorization from the ((department)) agency for any extension of the rental period.

(7) The ((department's)) agency's reimbursement amount for rented DME includes all of the following:

(a) Delivery to the client;

(b) Fitting, set-up, and adjustments;

(c) Maintenance, repair and/or replacement of the equipment; and

(d) Return pickup by the provider.

(8) The ((department)) agency considers rented equipment to be purchased after twelve months' rental unless the equipment is restricted as rental only.

(9) DME and related supplies, CRT, prosthetics, and orthotics purchased by the ((department)) agency for a client are the client's property.

(10) The ((department)) agency rents, but does not purchase, certain DME for clients. This includes, but is not limited to, the following:

(a) Bilirubin lights for newborns at home with jaundice; and

(b) Electric hospital-grade breast pumps.

(11) The ((department)) agency stops paying for any rented equipment effective the date of a client's death. The ((department)) agency prorates monthly rentals as appropriate.

(12) For a client who is eligible for both medicare and medicaid, the ((department)) agency pays only the client's coinsurance and deductibles. The ((department)) agency discontinues paying client's coinsurance and deductibles for rental equipment when either of the following applies:

(a) The reimbursement amount reaches medicare's reimbursement cap for the equipment; or

(b) Medicare considers the equipment purchased.

(13) The ((department)) agency does not obtain or pay for insurance coverage against liability, loss and/or damage to rental equipment that a provider supplies to a client.

(1) Hospital beds.

(a) The ((department)) medicaid agency covers, with prior authorization, one hospital bed in a ten-year period, per client, with the following limitations:

(i) A manual hospital bed as the primary option when the client has full-time caregivers; or

(ii) A semi-electric hospital bed only when:

(A) The client's medical need requires the client to be positioned in a way that is not possible in a regular bed and the position cannot be attained through less costly alternatives (e.g., the use of bedside rails, a trapeze, pillows, bolsters, rolled up towels or blankets);

(B) The client's medical condition requires immediate position changes;

(C) The client is able to operate the controls independently; and

(D) The client needs to be in the Trendelenburg position.

(b) The ((department)) agency bases the decision to rent or purchase a manual or semi-electric hospital bed on the length of time the client needs the bed.

(c) Rental - The ((department)) agency pays up to eleven months continuous rental of a hospital bed in a twelve-month period as follows:

(i) A manual hospital bed with mattress, with or without bed rails. The client must meet all of the following clinical criteria:

(A) Has a length of need/life expectancy that is twelve months or less;

(B) Has a medical condition that requires positioning of the body that cannot be accomplished in a standard bed (reason must be documented in the client's file);

(C) Has tried pillows, bolsters, and/or rolled up blankets/towels in client's own bed, and these have been determined to not be effective in meeting the client's positioning needs (nature of ineffectiveness must be documented in the client's file);

(D) Has a medical condition that necessitates upper body positioning at no less than a thirty-degree angle the majority of time the client is in the bed;

(E) Does not have full-time caregivers; and

(F) Does not also have a rental wheelchair.

(ii) A semi-electric hospital bed with mattress, with or without bed rails. The client must meet all of the following clinical criteria:

(A) Has a length of need/life expectancy that is twelve months or less;

(B) Has tried pillows, bolsters, and/or rolled up blankets/towels in own bed, and these have been determined to be ineffective in meeting positioning needs (nature of ineffectiveness must be documented in the client's file);

(C) Has a chronic or terminal condition such as chronic obstructive pulmonary disease (COPD), congestive ((health)) heart failure (CHF), lung cancer or cancer that has metastasized to the lungs, or other pulmonary conditions that cause the need for immediate upper body elevation;

(D) Must be able to independently and safely operate the bed controls; and

(E) Does not have a rental wheelchair.

(d) Purchase - The ((department)) agency pays, with prior authorization, for the initial purchase of a semi-electric hospital bed with mattress, with or without bed rails, when the following criteria are met:

(i) The client:

(A) Has a length of need/life expectancy that is twelve months or more;

(B) Has tried positioning devices such as pillows, bolsters, foam wedges, and/or rolled up blankets/towels in own bed, and these have been determined to be ineffective in meeting positioning needs (nature ((if)) of ineffectiveness must be documented in the client's file);

(C) Must be able to independently and safely operate the bed controls; and

(D) Is diagnosed:

(I) With quadriplegia;

(II) With tetraplegia;

(III) With duchenne muscular dystrophy;

(IV) With amyotrophic lateral sclerosis (ALS), often referred to as "Lou Gehrig's Disease";

(V) As ventilator-dependent; or

(VI) With ((chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF))) COPD or CHF with aspiration risk or shortness of breath that causes the need for an immediate change of upper body positioning of more than thirty degrees.

(ii) Requests for prior authorization must be submitted in writing to the ((department)) agency and be accompanied by:

(A) A completed General Information for Authorization form (((DSHS)) HCA 13-835) and Hospital Bed Evaluation form (((DSHS)) HCA 13-747). The ((department's)) agency's electronic forms are available online (see WAC ((388-543-7000)) 182-543-7000, Authorization);

(B) Documentation of the client's life expectancy, in months and/or years, the client's diagnosis, the client's date of delivery and serial number of the hospital bed; and

(C) Be accompanied by written documentation, from the client or caregiver, indicating the client has not been previously provided a hospital bed, purchase or rental.

(2) Mattresses and related equipment - The ((department)) agency pays, with prior authorization, for the following:

(a) Pressure pad, alternating with pump - One in a five-year period;

(b) Dry pressure mattress - One in a five-year period;

(c) Gel or gel-like pressure pad for mattress - One in a five-year period;

(d) Gel pressure mattress - One in a five-year period;

(e) Water pressure pad for mattress - One in a five-year period;

(f) Dry pressure pad for mattress - One in a five-year period;

(g) Mattress, inner spring - One in a five-year period; and

(h) Mattress, foam rubber - One in a five-year period.

The ((department)) medicaid agency covers the purchase of the following with the stated limitations, without prior authorization:

(1) Patient lift, hydraulic, with seat or sling - One per client in a five-year period.

(2) Traction equipment - One per client in a five-year period.

(3) Trapeze bars - One per client in a five-year period. The ((department)) agency requires prior authorization for rental.

(4) Fracture frames - One per client in a five-year period. The ((department)) agency requires prior authorization for rental.

(5) Transfer board or devices - One per client in a five-year period.

The ((department)) medicaid agency covers, without prior authorization, positioning devices with the following limitations:

(1) Positioning system/supine board (small or large), including padding, straps, adjustable armrests, footboard, and support blocks - One per client in a five-year period.

(2) Prone stander (infant, child, youth, or adult size) - One per client ((is)) in a five-year period. The prone stander must be prescribed by a physician and the client must not be residing in a skilled nursing facility.

(3) Adjustable standing frame (for child/adult who is thirty to sixty-eight inches tall), including two padded back support blocks, a chest strap, a pelvic strap, a pair of knee blocks, an abductor, and a pair of foot blocks - One per client in a five-year period.

(4) Positioning car seats - One per client, eight years of age and older or four feet nine inches or taller, in a five-year period.

(1) The ((department)) medicaid agency covers, with prior authorization, noninvasive osteogenesis electrical stimulators, limited to one per client, in a five-year period.

(2) The ((department)) agency pays for the purchase of nonspinal bone growth stimulators, only when:

(a) The stimulators have pulsed electromagnetic field (PEMF) simulation; and

(b) The client meets one or more of the following clinical criteria:

(i) Has a nonunion of a long bone fracture (which includes clavicle, humerus, phalanx, radius, ulna, femur, tibia, fibula, metacarpal and metatarsal) ((after)) where three months have elapsed since the date of injury without healing; or

(ii) Has a failed fusion of a joint other than in the spine where a minimum of nine months has elapsed since the last surgery.

(3) The ((department)) agency pays for the purchase of spinal bone growth stimulators, when:

(a) Prescribed by a neurologist, an orthopedic surgeon, or a neurosurgeon; and((;))

(b) The client meets one or more of the following clinical criteria:

(i) Has a failed spinal fusion where a minimum of nine months have elapsed since the last surgery; or

(ii) Is post-op from a multilevel spinal fusion surgery; or

(iii) Is post-op from spinal fusion surgery ((where)) and there is a history of a previously failed spinal fusion.

(1) The ((department)) medicaid agency covers:

(a) One artificial larynx, any type, without prior authorization, per client in a five-year period; and

(b) One speech generating device (SGD), with prior authorization, per client every two years.

(2) The ((department)) agency pays only for those approved ((speech generating devices ())SGDs(())) that have:

(a) Digitized speech output, using prerecorded messages;

(b) Synthesized speech output requiring message formation by spelling and access by physical contact with the device; or

(c) Synthesized speech output, permitting multiple methods of message formulation and multiple methods of device access.

(3) The ((department)) agency requires prior authorization for SGDs and reviews requests on a case-by-case basis. Requests to the ((department)) agency for prior authorization must meet all of the following:

(a) The client must have a severe expressive speech impairment and the client's medical condition warrants the use of a device to replace verbal communication (e.g., to communicate medical information); and

(b) The request must be in writing and be accompanied by:

(i) A completed General Information for Authorization form (((DSHS)) HCA 13-835). The ((department's)) agency's electronic forms are available online (see WAC ((388-543-7000)) 182-543-7000, Authorization); and

(ii) A completed Speech Language Pathologist (SLP) Evaluation for Speech Generating Devices ((form (DSHS)) (15-310) form. The ((department)) agency requires, at a minimum, the following information:

(A) A detailed description of the client's therapeutic history;

(B) A written assessment by a licensed ((speech language pathologist ())SLP(())); and

(C) Documentation of all of the following:

(I) The client has reliable and consistent motor response, which can be used to communicate with the help of an SGD;

(II) The client has demonstrated the cognitive and physical abilities to utilize the equipment effectively and independently to communicate; and

(III) The client's treatment plan includes a training schedule for the selected device.

(iii) A copy of the prescription for the SGD from the client's treating physician written on ((a department)) an agency Prescription Form (((DSHS)) HCA 13-794) (see WAC ((388-543-2000)) 182-543-2000(2)).

(4) The ((department)) agency may require trial-use rental of a SGD. The ((department)) agency applies the rental costs for the trial-use to the purchase price.

(5) The ((department)) agency pays for the repair or modification of an SGD when all of the following are met:

(a) All warranties are expired;

(b) The cost of the repair or modification is less than fifty percent of the cost of a new SGD and the provider has submitted supporting documentation; and

(c) The repair has a warranty for a minimum of ninety days.

(6) The ((department)) agency does not pay for devices requested for the purpose of education.

(7) The ((department)) agency pays for replacement batteries for a SGD in accordance with WAC ((388-543-5500)) 182-543-5500(3). The ((department)) agency does not pay for back-up batteries for ((a)) an SGD.

(8) Clients who are eligible for both medicare and medicaid must apply first to medicare for an SGD. If medicare denies the request and the client requests an SGD from the ((department)) agency, the ((department)) agency evaluates the request according to the rules of this section.

(1) The ((department)) medicaid agency covers the purchase of the following ambulatory aids with stated limitations, without prior authorization:

(a) Canes - One per client in a five-year period.

(b) Crutches - One per client in a five-year period.

(c) Walkers - One per client in a five-year period.

(2) The ((department)) agency pays for replacement underarm pads for crutches and replacement handgrips and tips for canes, crutches, and walkers. Prior authorization is not required.

(1) The ((department)) medicaid agency covers, with prior authorization, manual and power-drive wheelchairs for clients who reside at home. For clients who reside in a skilled nursing facility, see WAC ((388-543-5700)) 182-543-5700.

(2) For manual or power-drive wheelchairs for clients who reside at home, requests for prior authorization must include all of the following completed forms:

(a) General Information for Authorization form (((DSHS)) HCA 13-835). The ((department's)) agency's electronic forms are available online (see WAC ((388-543-7000)) 182-543-7000, Authorization);

(b) A Prescription Form (((DSHS)) HCA 13-794); and

(c) Medical Necessity for Wheelchair Purchase (for home clients only) form (((DSHS)) HCA 13-727) from the client's physician or therapist. The date on this form (((DSHS)) HCA 13-727) must not be prior to the date on the Prescription Form (((DSHS-)) HCA 13-794).

(3) The ((department)) agency does not pay for manual or power-drive wheelchairs that have been delivered to a client without prior authorization from the ((department)) agency.

(4) When the ((department)) agency determines that a wheelchair is medically necessary, according to the process found in WAC ((388-501-0165, for six months or less, the department)) 182-501-0165, the agency rents or purchases a wheelchair for clients who live at home. For clients who reside in a skilled nursing facility, see WAC ((388-543-5700)) 182-543-5700.

The ((department)) medicaid agency covers the rental or purchase of a manual wheelchair for a home client who is nonambulatory or has limited mobility and requires a wheelchair to participate in normal daily activities. For clients who reside in a skilled nursing facility, see WAC ((388-543-5700)) 182-543-5700.

(1) The ((department)) agency determines the type of manual wheelchair for a home client as follows:

(a) A standard wheelchair if the client's medical condition requires the client to have a wheelchair to participate in normal daily activities;

(b) A standard lightweight wheelchair if the client's medical condition is such that the client:

(i) Cannot self-propel a standard weight wheelchair; or

(ii) Requires custom modifications that cannot be provided on a standard weight wheelchair.

(c) A high-strength, lightweight wheelchair for a client:

(i) Whose medical condition is such that the client cannot self-propel a lightweight or standard weight wheelchair; or

(ii) Requires custom modifications that cannot be provided on a standard weight or lightweight wheelchair.

(d) A heavy duty wheelchair for a client who requires a specifically manufactured wheelchair designed to:

(i) Support a person weighing three hundred pounds or over; or

(ii) Accommodate a seat width up to twenty-two inches wide (not to be confused with custom heavy duty wheelchairs).

(e) A custom heavy duty wheelchair for a client who requires a specifically manufactured wheelchair designed to:

(i) Support a person weighing three hundred pounds or over; or

(ii) Accommodate a seat width over twenty-two inches wide.

(f) A rigid wheelchair for a client:

(i) With a medical condition that involves severe upper extremity weakness;

(ii) Who has a high level of activity; and

(iii) Who is unable to self-propel any of the above categories of wheelchair.

(g) A custom manufactured wheelchair for a client with a medical condition requiring wheelchair customization that cannot be obtained on any of the categories of wheelchairs listed in this section.

(h) Pediatric wheelchairs/positioning strollers having a narrower seat and shorter depths more suited to pediatric patients, usually adaptable to modifications for a growing child.

(2) The ((department)) agency pays for both a manual wheelchair and a power-drive wheelchair only for noninstitutionalized clients in limited circumstances. See WAC ((388-543-4200)) 182-543-4200(5).

(1) The ((department)) medicaid agency covers power-drive wheelchairs when the prescribing physician certifies that the following clinical criteria are met:

(a) The client can independently and safely operate a power-drive wheelchair;

(b) The client's medical condition negates his or her ability to self-propel any of the wheelchairs listed in the manual wheelchair category; and

(c) A power-drive wheelchair will:

(i) Provide the client the only means of independent mobility; or

(ii) Enable a child to achieve age-appropriate independence and developmental milestones.

(2) The following additional information is required for a three or four-wheeled power-drive scooter/power-operated vehicle (POV):

(a) The prescribing physician certifies that the client's condition is stable; and

(b) The client is unlikely to require a standard power-drive wheelchair within the next two years.

(3) When the ((department)) agency approves a power-drive wheelchair for a client who already has a manual wheelchair, the power-drive wheelchair becomes the client's primary chair, unless the client meets the criteria in subsection (5) of this section.

(4) The ((department)) agency pays to maintain only the client's primary wheelchair, unless the conditions of subsection (6) of this section apply.

(5) The ((department)) agency pays for one manual wheelchair and one power-drive wheelchair for noninstitutionalized clients only when one of the following circumstances applies:

(a) The architecture of the client's home is completely unsuitable for a power-drive wheelchair, such as narrow hallways, narrow doorways, steps at the entryway, and insufficient turning radius;

(b) The architecture of the client's home bathroom is such that power-drive wheelchair access is not possible, and the client needs a manual wheelchair to safely and successfully complete bathroom activities and maintain personal cleanliness; or

(c) The client has a power-drive wheelchair, but also requires a manual wheelchair because the power-drive wheelchair cannot be transported to meet the client's community, workplace, or educational activities. In this case, the manual wheelchair would allow the caregiver to transport the client in a standard automobile or van. The ((department)) agency requires the client's situation to meet the following conditions:

(i) The client's activities that require the second wheelchair must be located farther than one-fourth of a mile from the client's home; and

(ii) Cabulance, public buses, or personal transit are not available, practical, or possible for financial or other reasons.

(6) When the ((department)) agency approves both a manual wheelchair and a power-drive wheelchair for a noninstitutionalized client who meets one of the circumstances in subsection (5) of this section, the ((department)) agency pays to maintain both wheelchairs.

(1) The ((department)) agency covers, with prior authorization, wheelchair accessories and modifications that are specifically identified by the manufacturer as separate line item charges. To receive payment, providers must submit the following to the ((department)) agency:

(a) A completed General Information for Authorization form (((DSHS)) HCA 13-835). The ((department's)) agency's electronic forms are available online (see WAC ((388-543-7000)) 182-543-7000, Authorization);

(b) A completed Prescription Form (((DSHS)) HCA 13-794);

(c) A completed Medical Necessity for Wheelchair Purchase (for home clients only) form (((DSHS)) HCA 13-727). The date on this form (((DSHS)) HCA 13-727) must not be dated prior to the date on the Prescription Form (((DSHS-)) HCA 13-794);

(d) The make, model, and serial number of the wheelchair to be modified;

(e) The modification requested; and

(f) Any specific information regarding the client's medical condition that necessitates the modification.

(2) The ((department)) agency pays for transit option restraints only when used for client-owned vehicles.

(3) The ((department)) agency covers, with prior authorization, wheelchair repairs. To receive payment, providers must submit the following to the ((department)) agency:

(a) General Information for Authorization form (((DSHS)) HCA 13-835). The ((department's)) agency's electronic forms are available online (see WAC ((388-543-7000)) 182-543-7000);

(b) A completed Medical Necessity for Wheelchair Purchase form (for home clients only) (((DSHS)) HCA 13-727);

(c) The make, model, and serial number of the wheelchair to be repaired; and

(d) The repair requested.

(4) Prior authorization is required for the repair and modification of client-owned equipment.

(1) The agency covers, with prior authorization, individually configured, complex rehabilitation technology (CRT) products.

(2) CRT must be supplied by a CRT supplier with the appropriate taxonomy number to bill for the items.

(3) Each site that a company operates must employ at least one CRT professional who has been certified by the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).

(4) The client must be evaluated by a licensed health care provider who performs specialty evaluations within their scope of practice (occupational or physical therapists) and who does not have a financial relationship with the supplier.

(a) At the evaluation, a CRT professional must also be present from the company ordering the equipment; or

(b) The CRT provider must be present at the evaluation to:

(i) Assist in selection of the appropriate CRT item(s); and

(ii) Provide training in the use of the selected items.

(5) The CRT provider must:

(a) Provide service and repairs by qualified technicians for all CRT products it sells; and

(b) Provide written information to the client at the time of delivery as to how the client may receive services and repairs.

(1) The ((department)) agency covers, without prior authorization, the following prosthetics and orthotics, with stated limitations:

(a) Thoracic-hip-knee-ankle orthosis (THKAO) standing frame - One every five years.

(b) Preparatory, above knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot plaster socket, molded to model - One per lifetime, per limb.

(c) Preparatory, below knee "PTB" type socket, nonalignable system, pylon, no cover, SACH foot thermoplastic or equal, direct formed - One per lifetime, per limb.

(d) Socket replacement, below the knee, molded to patient model - One per twelve-month period, per limb.

(e) Socket replacement, above the knee/knee disarticulation, including attachment plate, molded to patient model - One per twelve-month period, per limb.

(f) All other prosthetics and orthotics are limited to one per twelve-month period per limb.

(2) The ((department)) agency pays only licensed prosthetic and orthotic providers to supply prosthetics and orthotics. This requirement does not apply to the following:

(a) Selected prosthetics and orthotics that do not require specialized skills to provide; and

(b) Out-of-state providers, who must meet the licensure requirements of that state.

(3) The ((department)) agency pays only for prosthetics or orthotics that are listed as such by the Centers for Medicare and Medicaid Services (CMS), ((formerly known as HCFA,)) that meet the definition of prosthetic ((and)) or orthotic as defined in WAC ((388-543-1000)) 182-543-1000 and are prescribed per WAC ((388-543-1100 and 388-543-1200)) 182-543-1100 and 182-543-1200.

(4) The ((department)) agency pays for repair or modification of a client's current prosthesis. To receive payment, all of the following must be met:

(a) All warranties are expired;

(b) The cost of the repair or modification is less than fifty percent of the cost of a new prosthesis and the provider has submitted supporting documentation; and

(c) The repair is warranted for a minimum of ninety days.

(5) The ((department)) agency requires the client to take responsibility for routine maintenance of a prosthetic or orthotic. If the client does not have the physical or mental ability to perform the task, the ((department)) agency requires the client's caregiver to be responsible. The ((department)) agency requires prior authorization for extensive maintenance to a prosthetic or orthotic.

(6) For prosthetics dispensed for purely cosmetic reasons, see WAC ((388-543-3800 [388-543-1300])) 182-543-6000, Noncovered-DME.

(1) The ((department's)) agency's skilled nursing facility per diem rate, established in chapters 74.46 RCW, 388-96, and 388-97 WAC, includes any reusable and disposable medical supplies that may be required for a skilled nursing facility client, unless otherwise specified within this section.

(2) The ((department)) agency pays for the following covered DME and related supplies and complex rehabilitation technology (CRT) outside of the skilled nursing facility per diem rate, subject to the limitations in this section:

(a) Manual or power-drive wheelchairs (including CRT);

(b) Speech generating devices (SGD); and

(c) Specialty beds.

(3) The ((department)) agency pays for one manual or one power-drive wheelchair for clients who reside in a skilled nursing facility, with prior authorization, according to the requirements in WAC ((388-543-4100, 388-543-4200, and 388-543-4300)) 182-543-4100, 182-543-4200, and 182-543-4300. Requests for prior authorization must:

(a) Be for the exclusive full-time use of a skilled nursing facility resident;

(b) Not be included in the skilled nursing facility's per diem rate;

(c) Include a completed General Information for Authorization form (((DSHS)) HCA 13-835);

(d) Include a copy of the telephone order, signed by the physician, for the wheelchair assessment;

(e) Include a completed Medical Necessity for Wheelchair Purchase for Nursing Facility Clients form (((DSHS)) HCA 13-729).

(4) The ((department)) agency pays for wheelchair accessories and modifications that are specifically identified by the manufacturer as separate line item charges, with prior authorization. To receive payment, providers must submit the following to the ((department)) agency:

(a) A ((completed Prescription form (DSHS 13-794))) copy of the telephone order, signed by the physician for the wheelchair accessories and modifications;

(b) A completed Medical Necessity for Wheelchair Purchase for Nursing Facility Clients form (((DSHS)) HCA 13-729). The date on this form (((DSHS 13-727))) (HCA 13-729) must not be prior to the date on the ((Prescription form (DSHS-13-794))) telephone order. The ((department's)) agency's electronic forms are available online (see WAC ((388-543-7000)) 182-543-7000, Authorization);

(c) The make, model, and serial number of the wheelchair to be modified;

(d) The modification requested; and

(e) Specific information regarding the client's medical condition that necessitates modification.

(5) The ((department)) agency pays for wheelchair repairs, with prior authorization. To receive payment, providers must submit the following to the ((department)) agency:

(a) A completed Medical Necessity for Wheelchair Purchase for Nursing Facility Clients form (((DSHS)) HCA 13-729). The ((department's)) agency's electronic forms are available online (see WAC ((388-543-7000)) 182-543-7000, Authorization);

(b) The make, model, and serial number of the wheelchair to be repaired; and

(c) The repair requested.

(6) Prior authorization is required for the repair and modification of client-owned equipment.

(7) The skilled nursing facility must provide a house wheelchair as part of the per diem rate, when the client resides in a skilled nursing facility.

(8) When the client is eligible for both medicare and medicaid and is residing in a skilled nursing facility in lieu of hospitalization, the ((department)) agency does not reimburse for DME and related supplies, CRT, prosthetics, orthotics, medical supplies, related services, ((and)) or related repairs ((and)) or labor charges under fee-for-service (FFS).

(9) The ((department)) agency pays for the purchase and repair of a speech generating device (SGD), with prior authorization. The ((department)) agency pays for replacement batteries for SGDs in accordance with WAC ((388-543-5500)) 182-543-5500(3).

(10) The ((department)) agency pays for the purchase or rental of a specialty bed (a heavy duty bariatric bed is not a specialty bed), with prior authorization, when:

(a) The specialty bed is intended to help the client heal; and

(b) The client's nutrition and laboratory values are within normal limits.

(11) The ((department)) agency considers decubitus care products to be included in the skilled nursing facility per diem rate and does not reimburse for these separately.

(12) See WAC ((388-543-9200)) 182-543-9200 for reimbursement for wheelchairs and WAC 182-543-9250 for reimbursement for CRT.

(13) The ((department)) agency pays for the following medical supplies for a client in a skilled nursing facility outside the skilled nursing facility per diem rate:

(a) Medical supplies or services that replace all or part((s)) of the function of a permanently impaired or malfunctioning internal body organ. This includes, but is not limited to, the following:

(i) Colostomy and other ostomy bags and necessary supplies (see WAC 388-97-1060(3)); and

(ii) Urinary retention catheters, tubes, and bags, excluding irrigation supplies.

(b) Supplies for intermittent catheterization programs, for the following purposes:

(i) Long term treatment of atonic bladder with a large capacity; and

(ii) Short term management for temporary bladder atony.

(c) Surgical dressings required as a result of a surgical procedure, for up to six weeks post-surgery.

The ((department)) medicaid agency pays for DME and related supplies, medical supplies and related services only when listed as covered in this chapter. The ((department)) agency evaluates a request for any durable medical equipment (DME) and related supplies, prosthetics, orthotics, and medical supplies listed as noncovered in this chapter under the provisions of WAC ((388-501-0160)) 182-501-0160. In addition to the noncovered services found in WAC ((388-501-0070)) 182-501-0070, the ((department)) agency does not cover:

(1) A client's utility bills, even if the operation or maintenance of medical equipment purchased or rented by the ((department)) agency for the client contributes to an increased utility bill;

(2) Instructional materials such as pamphlets and video tapes;

(3) Hairpieces or wigs;

(4) Material or services covered under manufacturers' warranties;

(5) Shoe lifts less than one inch, arch supports for flat feet, and nonorthopedic shoes;

(6) Supplies and equipment used during a physician office visit, such as tongue depressors and surgical gloves;

(7) Prosthetic devices dispensed for cosmetic reasons;

(8) Home improvements and structural modifications, including but not limited to the following:

(a) Automatic door openers for the house or garage;

(b) Electrical rewiring for any reason;

(c) Elevator systems and elevators;

(d) Installation of, or customization of existing, bathtubs or shower stalls;

(e) Lifts or ramps for the home;

(f) Overhead ceiling track lifts;

(g) Saunas;

(h) Security systems, burglar alarms, call buttons, lights, light dimmers, motion detectors, and similar devices;

(i) Swimming pools; and

(j) Whirlpool systems, such as jacuzzis, hot tubs, or spas.

(9) Nonmedical equipment, supplies, and related services, including but not limited to, the following:

(a) Back-packs, pouches, bags, baskets, or other carrying containers;

(b) Bedboards/conversion kits, and blanket lifters (e.g., for feet);

(c) Car seats for children seven years of age and younger or less than four feet nine inches tall, except for prior authorized positioning car seats under WAC ((388-543-3200)) 182-543-3200;

(d) Cleaning brushes and supplies, except for ostomy-related cleaners/supplies;

(e) Diathermy machines used to produce heat by high frequency current, ultrasonic waves, or microwave radiation;

(f) Electronic communication equipment, installation services, or service rates, including but not limited to, the following:

(i) Devices intended for amplifying voices (e.g., microphones);

(ii) Interactive communications computer programs used between patients and health care providers (e.g., hospitals, physicians), for self care home monitoring, or emergency response systems and services;

(iii) Two-way radios;

(iv) Rental of related equipment or services; and

(v) Devices requested for the purpose of education.

(g) Environmental control devices, such as air conditioners, air cleaners/purifiers, dehumidifiers, portable room heaters or fans (including ceiling fans), heating or cooling pads, and light boxes;

(h) Ergonomic equipment;

(i) ((Durable medical equipment)) DME that is used in a clinical setting;

(j) Exercise classes or equipment such as exercise mats, exercise balls, bicycles, tricycles, stair steppers, weights, or trampolines;

(k) Generators;

(l) Computer software other than speech generating software, printers, and computer accessories (such as anti-glare shields, backup memory cards);

(m) Computer utility bills, telephone bills, internet service bills, or technical support for computers or electronic notebooks;

(n) Any communication device that is useful to someone without severe speech impairment (including but not limited to cellular telephone and associated hardware, walkie-talkie, two-way radio, pager, or electronic notebook);

(o) Racing strollers/wheelchairs and purely recreational equipment;

(p) Room fresheners/deodorizers;

(q) Bidet or hygiene systems, "sharps" containers, paraffin bath units, and shampoo rings;

(r) Timers or electronic devices to turn things on or off, which are not an integral part of the equipment;

(s) Vacuum cleaners, carpet cleaners/deodorizers, and/or pesticides/insecticides; or

(t) Wheeled reclining chairs, lounge and/or lift chairs (including but not limited to geri-chair, posture guard, or lazy boy).

(10) Blood pressure monitoring:

(a) Sphygmomanometer/blood pressure apparatus with cuff and stethoscope;

(b) Blood pressure cuff only; and

(c) Automatic blood pressure monitor.

(11) Transcutaneous electrical nerve stimulation (TENS) devices and supplies, including battery chargers;

(12) Functional electrical stimulation (FES) bike;

(13) Wearable defibrillators;

(14) Disinfectant spray;

(15) Periwash;

(16) Bathroom equipment used inside or outside of the physical space of a bathroom:

(a) Bath stools;

(b) Bathtub wall rail (grab bars);

(c) Bed pans;

(d) Bedside commode chair;

(e) Control unit for electronic bowel irrigation/evacuation system;

(f) Disposable pack for use with electronic bowel system;

(g) Potty chairs;

(h) Raised toilet seat;

(i) Safety equipment (including but not limited to belt, harness or vest);

(j) Shower chairs;

(k) Shower/commode chairs;

(l) Sitz type bath or equipment;

(m) Standard and heavy duty bath chairs;

(n) Toilet rail;

(o) Transfer bench for tub or toilet;

(p) Urinal male/female.

(17) Personal and/or comfort items, including but not limited to the following:

(a) Bathroom and hygiene items, such as antiperspirant, astringent, bath gel, conditioner, deodorant, moisturizer, mouthwash, powder, shampoo, shaving cream, shower cap, shower curtains, soap (including antibacterial soap), toothpaste, towels, and weight scales;

(b) Full electric beds;

(c) Bedding items, such as mattress pads, blankets, mattress covers/bags, pillows, pillow cases/covers, sheets, and bumper pads;

(((c))) (d) Bedside items, such as bed trays, carafes, and over-the-bed tables;

(((d))) (e) Clothing and accessories, such as coats, gloves (including wheelchair gloves), hats, scarves, slippers, socks, custom vascular supports (CVS), surgical stockings, gradient compression stockings, and custom compression garments and lumbar supports for pregnancy;

(((e))) (f) Clothing protectors, surgical masks, and other protective cloth furniture coverings;

(((f))) (g) Cosmetics, including corrective formulations, hair depilatories, and products for skin bleaching, commercial sun screens, and tanning;

(((g))) (h) Diverter valves and handheld showers for bathtub;

(((h))) (i) Eating/feeding utensils;

(((i))) (j) Emesis basins, enema bags, and diaper wipes;

(((j))) (k) Health club memberships;

(((k))) (l) Hot or cold temperature food and drink containers/holders;

(((l))) (m) Hot water bottles and cold/hot packs or pads not otherwise covered by specialized therapy programs;

(((m))) (n) Impotence devices;

(((n))) (o) Insect repellants;

(((o))) (p) Massage equipment;

(((p))) (q) Medication dispensers, such as med-collators and count-a-dose, except as obtained under the compliance packaging program. See chapter ((388-530)) 182-530 WAC;

(((q))) (r) Medicine cabinet and first-aid items, such as adhesive bandages (e.g., Band-Aids, Curads), cotton balls, cotton-tipped swabs, medicine cups, thermometers, and tongue depressors;

(((r))) (s) Page turners;

(((s))) (t) Radio and television;

(((t))) (u) Telephones, telephone arms, cellular phones, electronic beepers, and other telephone messaging services;

(((u))) (v) Toothettes and toothbrushes, waterpics, and periodontal devices whether manual, battery-operated, or electric;

(18) Certain wheelchair features and options including, but not limited to, the following:

(a) Attendant controls (remote control devices);

(b) Canopies, including those used for strollers and other equipment;

(c) Clothing guards to protect clothing from dirt, mud, or water thrown up by the wheels (similar to mud flaps for cars);

(d) Decals;

(e) Hub Lock brake;

(f) Identification devices (such as labels, license plates, or name plates);

(g) Lighting systems;

(h) Replacement key or extra key;

(i) Speed conversion kits; and

(j) Trays for clients in a skilled nursing facility.

(19) New ((durable medical equipment)) DME, supplies, or related technology that the ((department)) agency has not evaluated for coverage. See WAC ((388-543-2100)) 182-543-2100.

(1) The ((department)) medicaid agency requires providers to obtain authorization for covered durable medical equipment (DME) and related supplies, complex rehabilitation technology (CRT), prosthetics, orthotics, medical supplies and related equipment((s)) as required in this chapter, in chapters ((388-501 and 388-502)) 182-501 and 182-502 WAC, and in published ((department)) billing instructions and/or ((numbered memoranda)) provider notices or when the clinical criteria required in this chapter are not met.

(a) For prior authorization (PA), a provider must submit a written request to the ((department)) agency as specified in the ((department's)) agency's published billing instructions (see WAC ((388-543-7100)) 182-543-7100). All requests for prior authorization must be accompanied by a completed General Information for Authorization form (((DSHS)) HCA 13-835) in addition to any program specific ((DSHS)) forms as required within this chapter. The ((department's)) agency's electronic forms are available online at: ((http://www.dshs.wa.gov/msa/forms/eforms.html)) http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx.

(b) For expedited prior authorization (EPA), a provider must meet the clinically appropriate EPA criteria outlined in the ((department's)) agency's published billing instructions. The appropriate EPA number must be used when the provider bills the ((department)) agency (see WAC ((388-543-7200)) 182-543-7200).

(2) When a service requires authorization, the provider must properly request authorization in accordance with the ((department's)) agency's rules, billing instructions, and ((numbered memoranda)) provider notices.

(3) The ((department's)) agency's authorization of service(s) does not necessarily guarantee payment.

(4) When authorization is not properly requested, the ((department)) agency rejects and returns the request to the provider for further action. The ((department)) agency does not consider the rejection of the request to be a denial of service.

(5) Authorization requirements in this chapter are not a denial of service to the client.

(6) The ((department)) agency may recoup any payment made to a provider if the ((department)) agency later determines that the service was not properly authorized or did not meet the EPA criteria. Refer to WAC ((388-502-0100)) 182-502-0100 (1)(c).

(1) The ((department)) medicaid agency requires providers to obtain prior authorization for certain items and services before delivering that item or service to the client, except for dual-eligible medicare/medicaid clients when medicare is the primary payer. The item or service must also be delivered to the client before the provider bills the ((department)) agency.

(2) All prior authorization requests must be accompanied by a completed General Information for Authorization form (((DSHS)) HCA 13-835), in addition to any program specific ((department)) agency forms as required within this chapter. ((Department)) Agency forms are available online at ((http://www.dshs.wa.gov/msa/forms/eforms.html)) http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx.

(3) When the ((department)) agency receives the initial request for prior authorization, the prescription(s) for those items or services must not be older than three months from the date the ((department)) agency receives the request.

(4) The ((department)) agency requires certain information from providers in order to prior authorize the purchase or rental of equipment. This information includes, but is not limited to, the following:

(a) The manufacturer's name;

(b) The equipment model and serial number;

(c) A detailed description of the item; and

(d) Any modifications required, including the product or accessory number as shown in the manufacturer's catalog.

(5) For prior authorization requests, the ((department)) agency requires the prescribing provider to furnish patient-specific justification for base equipment and each requested line item accessory or modification as identified by the manufacturer as a separate charge. The ((department)) agency does not accept general standards of care or industry standards for generalized equipment as justification.

(6) The ((department)) agency considers requests for new durable medical equipment (DME) and related supplies, complex rehabilitation technology (CRT), prosthetics, orthotics, medical supplies and related equipment((s)) that do not have assigned health care common procedure coding system (HCPCS) codes and are not listed in the ((department's)) agency's published issuances, including billing instructions or ((numbered memoranda)) provider notices. These items require prior authorization. The provider must furnish all of the following information to the ((department)) agency to establish medical necessity:

(a) A detailed description of the item(s) or service(s) to be provided;

(b) The cost or charge for the item(s);

(c) A copy of the manufacturer's invoice, price-list or catalog with the product description for the item(s) being provided; and

(d) A detailed explanation of how the requested item(s) differs from an already existing code description.

(7) The ((department)) agency does not pay for the purchase, rental, or repair of medical equipment that duplicates equipment that the client already owns ((or)), rents, or that the agency has authorized for the client. If the provider believes the purchase, rental, or repair of medical equipment is not duplicative, the provider must request prior authorization and submit the following to the ((department)) agency:

(a) Why the existing equipment no longer meets the client's medical needs; or

(b) Why the existing equipment could not be repaired or modified to meet the client's medical needs.

(c) Upon request, documentation showing how the client's condition met the criteria for PA or EPA.

(8) A provider may resubmit a request for prior authorization for an item or service that the ((department)) agency has denied. The ((department)) agency requires the provider to include new documentation that is relevant to the request.

(1) The ((department)) medicaid agency limits the amount, frequency, or duration of certain covered medical supplies and equipment(MSE), durable medical equipment (DME), and related supplies, prosthetics, orthotics, medical supplies, and related services, and reimburses up to the stated limit without requiring prior authorization.

(2) Certain covered items have limitations on quantity and frequency. These limits are designed to avoid the need for prior authorization for items normally considered medically necessary and for quantities sufficient for a thirty-day supply for one client.

(3) The ((department)) agency requires a provider to request prior authorization for a limitation extension (LE) in order to exceed the stated limits for nondurable medical equipment and medical supplies. All requests for prior authorization must be accompanied by a completed General Information for Authorization form (((DSHS)) HCA 13-835) in addition to any program specific ((DSHS)) forms as required within this chapter. ((Department)) Agency forms are available online at ((http://www.dshs.wa.gov/msa/forms/eforms.html)) http://www.hca.wa.gov/medicaid/forms/Pages/index.aspx.

(4) The ((department)) agency evaluates such requests for LE under the provisions of WAC ((388-501-0169)) 182-501-0169.

(1) The expedited prior authorization process (EPA) is designed to eliminate the need for written and telephonic requests for prior authorization for selected durable medical equipment (DME) procedure codes.

(2) The ((department)) medicaid agency requires a provider to create an authorization number for EPA for selected DME procedure codes. The process and criteria used to create the authorization number is explained in the ((department)) agency published DME-related billing instructions. The authorization number must be used when the provider bills the ((department)) agency.

(3) Upon request, a provider must provide documentation to the ((department)) agency showing how the client's condition met the criteria for EPA.

(4) A written or telephone request for prior authorization is required when a situation does not meet the EPA criteria for selected DME procedure codes.

(5) The ((department)) agency may recoup any payment made to a provider under this section if the provider did not follow the expedited authorization process and criteria.

(1) A provider must not bill the ((department)) medicaid agency for the rental or purchase of equipment supplied to the provider at no cost by suppliers/manufacturers.

(2) The ((department)) agency does not pay a durable medical equipment (DME) provider for medical supplies used in conjunction with a physician office visit. The ((department)) agency pays the office physician for these supplies when appropriate. Refer to the ((department's)) agency's physician-related services/health care professional services billing instructions.

If a fee-for-service (FFS) client enrolls in a ((department-contracted)) medicaid agency-contracted managed care organization (MCO), the following apply:

(1) The ((department)) agency stops paying for any rented equipment on the last day of the month preceding the month in which the client becomes enrolled in the MCO.

(2) The plan determines the client's continuing need for the equipment and is responsible for paying the provider.

(3) A client may become an MCO enrollee before the ((department)) agency completes the purchase of prescribed medical equipment. The ((department)) agency considers the purchase complete when the product is delivered and the ((department)) agency is notified of the serial number. If the client becomes an MCO enrollee before the ((department)) agency completes the purchase:

(a) The ((department)) agency rescinds the ((department's)) agency's authorization with the vendor until the MCO's primary care provider (PCP) evaluates the client; then

(b) The ((department)) agency requires the PCP to write a new prescription if the PCP determines the equipment is still medically necessary as defined in WAC ((388-500-0005)) 182-500-0070; then

(c) The MCO's applicable reimbursement policies apply to the purchase or rental of the equipment.

(4) If a client ((may be)) is disenrolled from an MCO and placed into fee-for-service before the MCO completes the purchase of prescribed medical equipment((.)):

(a) The ((department)) agency rescinds the MCO's authorization with the vendor until the client's primary care provider (PCP) evaluates the client; then

(b) The ((department)) agency requires the PCP to write a new prescription if the PCP determines the equipment is still medically necessary as defined in WAC ((388-500-0005)) 182-500-0070; then

(c) The ((department's)) agency's applicable reimbursement policies apply to the purchase or rental of the equipment.

If a client is eligible for both medicare and medicaid, the following apply:

(1) The ((department)) medicaid agency requires a provider to accept medicare assignment before any medicaid reimbursement;

(2) In accordance with WAC ((388-502-0110)) 182-502-0110(3):

(a) If the service provided is covered by medicare and medicaid, the ((department)) agency pays only the deductible and/or coinsurance up to medicare's or medicaid's allowed amount, whichever is less.

(b) If the service provided is covered by medicare but is not covered by the ((department)) agency, the ((department)) agency pays only the deductible and/or coinsurance up to medicare's allowed amount.

(1) The ((department)) medicaid agency pays qualified providers who meet all of the conditions in WAC ((388-502-0100)) 182-502-0100, for durable medical equipment (DME), supplies, repairs, and related services provided on a fee-for-service (FFS) basis as follows:

(a) To ((department-enrolled)) agency-enrolled DME providers, qualified complex rehabilitation technology (CRT) suppliers, pharmacies, and home health agencies under their national provider identifier (NPI) numbers, subject to the limitations of this chapter, and according to the procedures and codes in the ((department's)) agency's current DME billing instructions; and

(b) In accordance with the health care common procedure coding system (HCPCS) guidelines for product classification and code assignation.

(2) The ((department)) agency sets, evaluates, and updates the maximum allowable fees for DME and related supplies, CRT, prosthetics, orthotics, medical supplies and related services at least once yearly using available published information, including but not limited to:

(a) Commercial ((databases)) data bases;

(b) Manufacturers' catalogs;

(c) Medicare fee schedules; and

(d) Wholesale prices.

(3) The ((department)) agency may adopt policies, procedure codes, and/or rates that are inconsistent with those set by medicare if the ((department)) agency determines that such actions are necessary.

(4) The ((department)) agency updates the maximum allowable fees for DME and related supplies, CRT, prosthetics, orthotics, medical supplies and related services at least once per year, unless otherwise directed by the legislature or deemed necessary by the ((department)) agency.

(5) The ((department's)) agency's maximum payment for DME and related supplies, CRT, prosthetics, orthotics, medical supplies and related services is the lesser of either of the following:

(a) Providers' usual and customary charges; or

(b) Established rates, except as provided in WAC ((388-543-8200)) 182-543-8200.

(6) The ((department)) agency is the payor of last resort for clients with medicare or third party insurance.

(7) The ((department)) agency does not pay for medical equipment and/or services provided to a client who is enrolled in ((a department-contracted)) an agency-contracted managed care plan, but who did not use one of the plan's participating providers.

(8) The ((department's)) agency's reimbursement rate for purchased or rented covered DME and related supplies, prosthetics, orthotics, medical supplies and related services includes all of the following:

(a) Any adjustments or modifications to the equipment that are required within three months of the date of delivery or are covered under the manufacturer's warranty. This does not apply to adjustments required because of changes in the client's medical condition;

(b) Any pick-up and/or delivery fees or associated costs (e.g., mileage, travel time, gas, etc.);

(c) Telephone calls;

(d) Shipping, handling, and/or postage;

(e) Routine maintenance of DME that includes testing, cleaning, regulating, and assessing the client's equipment;

(f) Fitting and/or set-up; and

(g) Instruction to the client or client's caregiver in the appropriate use of the equipment, device, and/or supplies.

(9) DME, supplies, repairs, and related services supplied to eligible clients under the following reimbursement methodologies are included in those methodologies and are not reimbursed under fee-for-service:

(((i))) (a) Hospice providers' per diem reimbursement;

(((ii))) (b) Hospitals' diagnosis-related group (DRG) reimbursement;

(((iii))) (c) Managed care plans' capitation rate;

(((iv))) (d) Skilled nursing facilities' per diem rate; and

(((v))) (e) Professional services' resource-based relative value system reimbursement (RBRVS) rate.

(10) The provider must make warranty information, including date of purchase, applicable serial number, model number or other unique identifier of the equipment, and warranty period, available to the ((department)) agency upon request.

(11) The dispensing provider who furnishes the equipment, supply or device to a client is responsible for any costs incurred to have a different provider repair the equipment when:

(a) Any equipment that the ((department)) agency considers purchased requires repair during the applicable warranty period;

(b) The provider refuses or is unable to fulfill the warranty; and

(c) The equipment, supply or device continues to be medically necessary.

(12) If the rental equipment, supply or device must be replaced during the warranty period, the ((department)) agency recoups fifty percent of the total amount previously paid toward rental and eventual purchase of the equipment, supply or device delivered to the client if:

(a) The provider is unwilling or unable to fulfill the warranty; and

(b) The equipment, supply or device continues to be medically necessary.

(13) See WAC ((388-543-9100, 388-543-9200, 388-543-9300, and 388-543-9400)) 182-543-9100, 182-543-9200, 182-543-9300, and 182-543-9400 for other reimbursement methodologies.

(1) The agency sets, evaluates and updates the maximum allowable fees for purchased other durable medical equipment (DME) at least once yearly using one or more of the following:

(a) The current medicare rate, as established by the federal centers for medicare and medicaid services (CMS), for a new purchase if a medicare rate is available;

(b) A pricing cluster; or

(c) On a by report basis.

(2) Establishing reimbursement rates for purchased other DME based on pricing clusters.

(a) A pricing cluster is based on a specific health care common procedure coding system (HCPCS) code.

(b) The agency's pricing cluster is made up of all the brands/models for which the agency obtains pricing information. However, the agency may limit the number of brands/models included in the pricing cluster. The agency considers all of the following when establishing the pricing cluster:

(i) A client's medical needs;

(ii) Product quality;

(iii) Introduction, substitution or discontinuation of certain brands/models; and/or

(iv) Cost.

(c) When establishing the fee for other DME items in a pricing cluster, the maximum allowable fee is the median amount of available manufacturers' list prices for all brands/models as noted in subsection (2)(b) of this section.

(3) The agency evaluates a by report (BR) item, procedure, or service for medical necessity, appropriateness and reimbursement value on a case-by-case basis. The agency calculates the reimbursement rate for these items at eighty percent of the manufacturer's list or manufacturer's suggested retail price (MSRP) as of July 31st of the base year or one hundred twenty-five percent of the wholesale acquisition cost from the manufacturer's invoice.

(4) Monthly rental reimbursement rates for other DME. The agency's maximum allowable fee for monthly rental is established using one of the following:

(a) For items with a monthly rental rate on the current medicare fee schedule as established by ((the federal Centers for Medicare and Medicaid Services ())CMS(())), the agency equates its maximum allowable fee for monthly rental to the current medicare monthly rental rate;

(b) For items that have a new purchase rate but no monthly rental rate on the current medicare fee schedule as established by ((the federal Centers for Medicare and Medicaid Services ())CMS(())), the agency sets the maximum allowable fee for monthly rental at one-tenth of the new purchase price of the current medicare rate;

(c) For items not included in the current medicare fee schedule as established by ((the federal Centers for Medicare and Medicaid Services ())CMS(())), the agency considers the maximum allowable monthly reimbursement rate as by report. The agency calculates the monthly reimbursement rate for these items at one-tenth of eighty percent of the manufacturer's list or ((manufacturer's suggested retail price ())MSRP(())).

(5) Daily rental reimbursement rates for other DME. The agency's maximum allowable fee for daily rental is established using one of the following:

(a) For items with a daily rental rate on the current medicare fee schedule as established by ((the Centers for Medicare and Medicaid Services ())CMS(())), the agency equates its maximum allowable fee for daily rental to the current medicare daily rental rate;

(b) For items that have a new purchase rate but no daily rental rate on the current medicare fee schedule as established by CMS, the agency sets the maximum allowable fee for daily rental at one-three-hundredth of the new purchase price of the current medicare rate;

(c) For items not included in the current medicare fee schedule as established by CMS, the agency considers the maximum allowable daily reimbursement rate as by report. The agency calculates the daily reimbursement rate at one-three-hundredth of eighty percent of the manufacturer's list or ((manufacturer's suggested retail price ())MSRP(())) as of July 31st of the base year or one hundred twenty-five percent of the wholesale acquisition cost from the manufacturer's invoice.

(6) The agency does not reimburse for DME and related supplies, prosthetics, orthotics, medical supplies, related services, and related repairs and labor charges under fee-for-service (((FFS))) when the client is any of the following:

(a) An inpatient hospital client;

(b) Eligible for both medicare and medicaid, and is staying in a skilled nursing facility in lieu of hospitalization;

(c) Terminally ill and receiving hospice care; or

(d) Enrolled in a risk-based managed care plan that includes coverage for such items and/or services.

(7) The agency rescinds any purchase order for a prescribed item if the equipment was not delivered to the client before the client:

(a) Dies;

(b) Loses medical eligibility;

(c) Becomes covered by a hospice agency; or

(d) Becomes covered by a managed care organization.

(8) A provider may incur extra costs for customized equipment that may not be easily resold. In these cases, for purchase orders rescinded in subsection (7) of this section, the agency may pay the provider an amount it considers appropriate to help defray these extra costs. The agency requires the provider to submit justification sufficient to support such a claim.

(9) The agency may adopt policies, procedure codes, and/or rates that are inconsistent with those set by medicare if the agency determines that such actions are necessary.

(1) The agency reimburses a DME provider for purchased wheelchairs based on the ((specific brand and model of wheelchair dispensed. The agency decides which brands and/or models of wheelchairs are eligible for reimbursement based on all of the following:

(d) Available alternatives)) assigned health care common procedure coding system (HCPCS) code. The agency requires providers to make sure the specific brand and model of wheelchairs dispensed are coded according to the Centers for Medicare and Medicaid Services' (CMS) pricing, data analysis, and coding (PDAC) web site.

(2) The agency sets, evaluates and updates the maximum allowable fees at least once yearly for wheelchair purchases((,)) and wheelchair rentals((, and wheelchair accessories (e.g., cushions and backs))) using the lesser of the following:

(a) The current medicare fees;

(b) ((The actual invoice for the specific item)) A pricing cluster; or

(c) On a by-report (BR) basis.

(4) The agency evaluates a BR item, procedure, or service for medical necessity, appropriateness and reimbursement value on a case-by-case basis. The agency calculates the reimbursement rate for these items at a percentage of the manufacturer's list or manufacturer's suggested retail price (MSRP) as of January 31st of the base year, or a percentage of the wholesale acquisition cost (AC). The agency uses the following percentages:

(((i))) (a) For basic standard wheelchairs, sixty-five percent of MSRP or one hundred forty percent of AC;

(((ii))) (b) For ((add-on accessories and)) parts, eighty-four percent of MSRP or one hundred forty percent of AC;

(((iii))) (c) For ((up-charge modifications and)) seat and back cushions, eighty percent of MSRP or one hundred forty percent of AC((;

(5) The agency may adopt policies, procedure codes, and/or rates that are inconsistent with those set by medicare if the agency determines that such actions are necessary.

(1) The agency reimburses a complex rehabilitation technology (CRT) provider for purchased CRT products based on the assigned health care common procedure coding system (HCPCS) code. The agency requires providers to make sure the specific brand and model of CRT products dispensed are coded according to the Centers for Medicare and Medicaid Services' (CMS) pricing, data analysis, and coding (PDAC) web site.

(2) The agency sets, evaluates, and updates the maximum allowable fees at least once yearly for CRT products using the lesser of the following:

(a) The current medicare fees;

(b) A pricing cluster; or

(c) On a by-report basis.

(3) Establishing reimbursement rates for purchased CRT products based on pricing clusters.

(a) A pricing cluster is based on a specific HCPCS code.

(b) The agency's pricing cluster is made up of all of the brands/models for which the agency obtains pricing information. However, the agency may limit the number of brands/models included in the pricing cluster. The agency considers all of the following when establishing the pricing cluster:

(i) A client's medical needs;

(ii) Product quality;

(iii) Introduction, substitution or discontinuation of certain brands/models; and

(iv) Costs.

(c) When establishing the fee for CRT products in a pricing cluster, the maximum allowable fee is the median amount of available manufacturer's list prices for all brands/models as noted in (b) of this subsection.

(4) The agency evaluates by-report (BR) items, procedure, or service for medical necessity, appropriateness and reimbursement value on a case-by-case basis. The agency calculates the reimbursement rate for these items at a percentage of the manufacturer's suggested retail price (MSRP) as of January 31st of the base year, or a percentage of the wholesale acquisition cost (AC) from the manufacturer's invoice. The agency uses the following percentages:

(a) For add-on CRT accessories and parts, eighty-four percent of MSRP or one hundred forty percent of AC;

(b) For up-charge modifications, seating systems, back and seat cushions, eighty percent of MSRP or one hundred forty percent of AC;

(c) For CRT manual wheelchair base, eighty percent of MSRP or one hundred forty percent of AC; and

(d) For CRT power-drive wheelchair base, eighty-five percent of MSRP or one hundred forty percent of AC.

(5) The agency may adopt policies, procedure codes, and/or rates that are inconsistent with those set by medicare if the agency determines that such actions are necessary.