PDFWAC 182-554-600

Covered enteral nutrition products, equipment and related supplies—Tube-delivered.

(1) General. The agency covers tube-delivered enteral nutrition products, equipment, and related supplies, regardless of age if the client:
(a) Has a valid prescription under WAC 182-554-400, which must be submitted within three months of the date the prescriber signed the prescription;
(b) Can manage tube feedings:
(i) Independently; or
(ii) With a caregiver's assistance; and
(c) Has at least one of the following medical conditions:
(i) A disease or condition that impairs the client's ability to ingest sufficient calories and nutrients or restricts calories and nutrients from reaching the client's gastrointestinal tract; or
(ii) A disease or condition of the small bowel that impairs digestion and absorption of an oral diet, either of which requires tube feedings to provide sufficient nutrients to maintain weight and strength that is properly proportioned to the client's overall health status.
(2) Limitations. The following limitations apply to the agency's payment for covered tube-delivered enteral nutrition products, equipment and related supplies. The agency pays for:
(a) One purchased pump, per client, in a five-year period;
(b) One purchased nondisposable intravenous pole required for enteral nutrition product delivery, per client, per lifetime; and
(c) No more than twelve months of equipment rental. After twelve months the agency considers the equipment purchased and it becomes the client's property.
(3) Women, infants, and children (WIC) program.
(a) If the client is age four or younger, the client must have a signed and dated written notification from the WIC program to receive tube delivered enteral nutrition products. The notice must verify:
(i) The client is not eligible for the WIC program; or
(ii) The client is eligible for the WIC program, but the client's need for a tube delivered enteral nutrition product exceeds WIC's allowed amount.
(b) If the client is age four or younger and is unable to receive a necessary tube delivered enteral nutrition product from WIC, the provider must keep the following information in the client's file:
(i) Documentation that the requested tube delivered product is not available through the WIC program; or
(ii) Reasons why a similar WIC product does not meet the client's needs.
(4) Authorization.
(a) If the client meets the criteria in subsection (1) of this section, the provider must follow the agency's expedited prior authorization (EPA) process to receive payment.
(b) If the client does not meet the criteria in subsection (1) of this section, the provider must submit a request for prior authorization (PA). The PA request must meet the requirements under WAC 182-554-700(3).
(c) The agency pays for enteral equipment replacement parts with PA if the equipment is:
(i) Owned by the client;
(ii) Less than five years old; and
(iii) No longer under warranty.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-08-009, § 182-554-600, filed 3/24/17, effective 5/1/17. WSR 11-14-075, recodified as § 182-554-600, filed 6/30/11, effective 7/1/11. Statutory Authority: 2009 c 564 § 1109, RCW 74.04.050, and 74.08.090. WSR 10-01-138, § 388-554-600, filed 12/21/09, effective 1/21/10. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-554-600, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.08.090, 74.09.530 and chapter 74.09 RCW. WSR 05-04-059, § 388-554-600, filed 1/28/05, effective 3/1/05.]