Date of Adoption: December 13, 2000.

Purpose: The department is establishing a new chapter for durable medical equipment, chapter 388-543 WAC, so that all the rules relating to this subject will be contained in one WAC chapter. The new chapter codifies current policy and payment methodology, in compliance with Failor's Pharmacy v. DSHS lawsuit. The proposed rules have been written to comply with the Governor's Executive Order 97-02.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.530.

Adopted under notice filed as WSR 00-13-008 on June 9, 2000.

Changes Other than Editing from Proposed to Adopted Version:      WAC 388-543-1000:

     "Expedited prior authorization" means the process for obtaining authorization that must be used for selected durable medical equipment....

     "Limitation extension" means an authorization process to exceed coverage limitations (quantity, frequency, or duration) set in WAC, billing instructions, or numbered memoranda. Limitation extensions require prior authorization.

     "Medical supplies" means 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.

     "Personal or comfort item" means an item or service, which primarily serves the comfort or convenience of the client. These items or services do not contribute meaningfully to the treatment of an illness or injury or the functioning of a malformed body member.

     "Prior authorization" means a process by which clients or providers must request and receive MAA approval for certain medical equipment and related supplies, prosthetics, orthotics, medical supplies and related services, based on medical necessity, before the services are provided to clients, as a precondition for provider reimbursement. Expedited prior authorization and limitation extension are forms types of prior authorization.

     "Three- or four-wheeled scooter" (5) Pneumatic rear tires. Tires designed for indoor/outdoor use.

     "Wheelchair - manual" means a federally-approved, nonmotorized wheelchair that can be is capable of being independently propelled by a client using his or her upper extremities and fits one of the following categories:....

     WAC 388-543-1100:

     (1) MAA covers only those DME and related supplies, prosthetics, orthotics, medical supplies and related services, repairs and labor charges, listed in MAA's published issuances (This proposed (1) renumbered as (6) as shown below.)

     (2) (((2))) The Medical Assistance Administration (MAA) covers DME and related supplies, prosthetics, orthotics, medical supplies, related services, repairs and labor charges when all of the following apply. They must be:

     (f) Justified as Medically necessary as determined by MAA defined in WAC 388-500-0005. The provider or client must submit sufficient objective evidence to establish medical necessity. Information used to establish medical necessity includes, but is not limited to, the following:... (Proposed WAC 388-543-1100(2) renumbered as (1).)

     (2) MAA evaluates a request for any equipment or devices that are listed as noncovered in WAC 388-543-1300 under the provisions of WAC 388-501-0165.

     (3) MAA evaluates a request for a service that is in a covered category but has been determined to be experimental or investigational under WAC 388-531-0050, under the provisions of WAC 388-501-0165 which relate to medical necessity.

     (4) MAA evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions when medically necessary, under the standards for covered services in WAC 388-501-0165.

     (5) (3) MAA 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:... (Proposed WAC 388-531-1100(3) renumbered as (5).)

     (6) (1) MAA covers only those DME medical equipment and related supplies, prosthetics, medical supplies and related services, repairs and labor charges, listed in MAA's published issuances, including Washington Administrative Code (WAC), billing instructions, and numbered memoranda. (Proposed WAC 388-531-1100(1) renumbered as (6).)

     (7) (4) MAA considers new technologies available through manufacturers to be noncovered unless MAA establishes coverage by assigning the technology a new procedure code an a reimbursement rate, or by assigning an existing procedure code. A manufacturer An interested party may request MAA to include new equipment/supplies in the billing instructions by sending a written request plass [plus] all of the following:

     (d) Any additional information the manufacturer requestor feels is important. (Proposed WAC 388-531-1100(4) renumbered as (7).)

     (8) (5) MAA bases the decision to purchase or rent DME for a client, or to pay for repairs to client-owned equipment on the least costly and/or equally effective alternative medical necessity. (Proposed WAC 388-531-1100(5) renumbered as (8).)

     (9) (6) MAA covers replacement batteries for purchased medically necessary DME equipment covered within this chapter. (Proposed WAC 388-531-1100(6) renumbered as (9).)

     (10) (7) MAA covers the following categories of medical equipment and supplies only when they are... (Proposed WAC 388-531-1100(7) renumbered as (10).)

     (11) (8) MAA evaluates a BR item, procedure, or service for its medical appropriateness and reimbursement value on a case-by-case basis. (Proposed WAC 388-531-1100(8) renumbered as (11).)

     (12) (9) For a client in a nursing facility, MAA covers only the following when medically necessary. All other DME and supplies identified in MAA billing instructions are the responsibility of the nursing facility, in accordance with chapters 388-96 and 388-97 WAC. See also WAC 388-543-2900 (3) and (4). MAA covers:

     (a) The purchase and repair of an augmentative communication device (ACD), a wheelchair for the exclusive full-time use of a permanently disabled nursing facility resident when the wheelchair is not included in the nursing facility's per diem rate, or specialty bed; and

     (b) The rental of a specialty bed. (Proposed WAC 388-531-1100(9) renumbered as (12).)

     (13) Vendors must provide instructions for use of equipment; therefore instructional materials such as pamphlets and video tapes are not covered.

     (14) Bilirubin lights are limited to rentals for at-home newborns with jaundice.

     WAC 388-543-1200:

     (1)(c) ...billed to the department. Out-of-state prosthetic and orthotics providers must meet their state regulatory requirements.

     (2)(d) ...relative value scale (RBRVS); and

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

     WAC 388-543-1300 Noncovered Equipment, related supplies and services or other nonmedical equipment supplies, and devices that are not covered.

     MAA pays only for medical equipment DME and related supplies, and services that are medically necessary, listed as covered, and meet MAA's the definition of DME and medical supplies as defined in WAC 388-542-1000 and prescribed per WAC 388-543-1100 and 1200. MAA pays only for prosthetics and orthotics that are listed as such by HCFA, meet the definitions of prosthetic and orthotic as defined in WAC 388-542-1000, and prescribed per WAC 388-542-1100 and 1200. . DME means equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of illness or injury, and is appropriate for use in the client's place of residence. MAA considers all requests for covered DME, related supplies and services, medical supplies, prosthetics, orthotics, and related services, and noncovered equipment and-related supplies, prosthetics, orthotics, medical supplies and related services, will be reviewed based on under the provisions of WAC 388-501-0165(8) which relate to medical necessity. When MAA considers that a request does not meet the requirements for medical necessity, the definition(s) of covered item(s), or is not covered, the client may appeal that decision under the provisions of WAC 388-501-0165. Case-by-case exceptions will only be considered based on WAC 388-501-0160. MAA specifically excludes services and equipment in this chapter from fee-for-service (FFS) scope of coverage when the services and equipment do not meet the definition for a covered item, or the services are not typically medically necessary. This exclusion...

     (3) More costly services or equipment when MAA determines that less costly, equally effective services or equipment are available;

     (4) (3) A client's utility bills, even if operation or maintenance of medical equipment purchased or rented by MAA for the client contributes to an increased utility bill (refer to the Aging and Adult Services Administration's (AASA) COPES program for potential coverage);

     (5) Bilirubin lights, except as rentals, for at-home newborns with jaundice; (subsequent listing renumbered appropriately).

     (8) Procedures, prosthetics, or supplies related to gender dysphoria surgery; (subsequent listing renumbered appropriately).

     (10) (7) Outpatient office visit supplies and equipment used during a physician office visit, such as tongue depressors and surgical gloves;

     (11) (8) Temporary prostheses or Prosthetic devices dispensed solely for cosmetic reasons (refer to WAC 388-531-0150 (1)(d));

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

     (f) Structural modifications of any kind to a client's house, including but not limited to, the following:

     (i) (f) Electrical wiring...

     (ii) (g) Elevator systems and elevators, ceiling lifts and ceiling tracks, stair lifts.; and

     (iii) (h) Wheelchair Lifts or ramps...

     (iv) (i) Installation of...

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

     (a) Backpacks, pouches, bags, baskets, or other carrying containers for use with aids to mobility:

     (b) Bed wetting (Enuresis) prevention training equipment;     (c) (b) Beds other than hospital, Bedboards/conversion kits...(subsequent listing renumbered appropriately).

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

     (ii) Interactive communications computer programs used between patients and healthcare providers (e.g., hospitals, physicians), for self care home monitoring, or emergency response systems and services (refer to AASA COPES or outpatient hospital programs for emergency response systems and services);

     (m) (k) ...other than specified in WAC 388-543-23002200;

     (l) Istructional materials, such as pamphlets and videotapes; (subsequent listing renumbered appropriately).

     (n) (l) Racing strollers/wheelchairs and purely recreational equipment;

     (p) (n) Sitz bath, Bidet or...

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

     (14) (11) Personal and comfort items that do not meet the DME definition, including but not limited to the following:... (subsequent listing renumbered appropriately).

     (a) Bathroom items, such as antiperspirant, astringent, bath gel, conditioner, deodorant, moisturizer, mouthwash, powder, sanitary napkins (e.g., Kotex), shampoo, shaving cream, shower cap, shower curtains, soap (including antibacterial soap), toothpaste, towels, and weight scales.

     (e) Clothing protectors and other protective cloth furniture coverings as protection against incontinence;

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

     (i) Emesis basins, enema bags, peri-wash, and diaper wipes;

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

     (15) (12)(g) Tie-down restraints, except where medically necessary for client owned vehicles.

     WAC 388-543-1400:

     (2) MAA sets maximum allowable fees for DME medical equipment...

     (4) MAA updates the maximum allowable fees for DME medical equipment...

     (9) MAA does not cover medical equipment and/or services provided to a client who is enrolled in a MAA-contracted managed care plan, but did not use one of the plan's participating providers.

     WAC 388-543-1600:

     (1) MAA bases its determination about which DME and related supplies, prosthetics, orthotics, medical supplies and related services require prior authorization (PA) or expedited prior authorization (EPA) on utilization criteria. (See WAC 388-543-1000 for PA and WAC 388-543-1800 for EPA). MAA considers all of the following when establishing utilization criteria:

     (a) High cost;

     (b) Potential for utilization abuse;

     (c) Narrow therapeutic indication; and

     (d) Safety.

     (2) MAA requires providers to obtain prior authorization for certain items and services... (Items proposed as (1) through (16) renumbered as (2)(a) through (q).)

     (p) ...procedure code; and

     (q) Limitation extensions.

     WAC 388-543-1700:

     (6) If a client becomes ineligible before the end of the month, MAA stops paying for any rented equipment effective the date the client becomes ineligible. (subsequent listing renumbered appropriately).

     WAC 388-543-1800:

     (8) MAA denies a request for an item when a less costly, equally effective alternative is available that will meet the client's medical needs. MAA informs the provider and/or the client of a less costly alternative from MAA's manufacturer's literature on file when an MAA denial of a request is based on a less costly, equally effective alternative being available.

     WAC 388-543-2000:

     (1) MAA purchases a wheelchair for a client when MAA determines that a wheelchair is medically necessary for more than six months. MAA bases its decisions regarding requests for wheelchairs on medical necessity and on a case-by-case basis.

     (3) MAA considers rental or purchase of a manual wheelchair if the for a home client who is nonambulatory or...

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

     (4) MAA considers a power-drive wheelchair only if when the client's medical needs cannot be met by a less costly means of mobility.

     (a) The client has severe abnormal upper extremity weakness and the extent of the impairment is documented. (subsequent listing renumbered appropriately).

     (d) All other circumstances will be considered based on medical necessity and on a case-by-case basis.

     (6) In order to consider purchasing a wheelchair, MAA requires the provider to submit the following information from the prescribing physician, physical therapist, or occupational therapist.

     (10)(c)(iii) All other circumstances will be considered on a case-by-case basis, based on medical necessity.

     WAC 388-543-2200:

     (1) MAA considers all requests on a case-by-case basis for augmentative communication devices (ACDs) for the purpose of appropriately relaying medical information.

     (2)(d) Documented trials of each ACD that the client has tried. This includes less costly types/models, and the effectiveness of each device in promoting the client's ability to communicate with health care providers, and caregivers, and others.

     (3)(c)(ii) ...personal care needs; and

     (iv) Improve excessive communication skills, vocabulary, and understanding; and

     (v) Attain specific speech therapy goals and objectives in the speech treatment or training plan.

     (4) MAA covers ACDs only once every two years for a client who meets the criteria in subsection (3) of this section. MAA does not approve a new or updated component, modification, or replacement model for a client whose ACD is less than two years old. MAA may make exceptions to the criteria in this subsection (3) of this section based strictly on a finding of unforeseeable and significant changes to the client's medical condition.

     WAC 388-543-2300:

     (3) All other circumstances will be considered on a case-by-case basis, based on medical necessity.

     WAC 388-543-2400:

     (1) Beds covered by MAA are limited to hospital beds for rental or purchase. MAA bases the decision to rent or purchase a manual, semi-electric, or full electric hospital bed on the length of time the client needs the bed, as follows:...

     WAC 388-543-2400:

     (1)(a) MAA initially authorizes a maximum of two months rental for a short-term need. Upon request, MAA may allow limitation extensions as medically necessary.

     WAC 388-543-2400:

     (4) All other circumstances will be considered on a case-by-case basis, based on medical necessity.

     WAC 388-543-2600:

     (1) MAA reimburses for prosthetics and orthotics to licensed prosthetic and orthotic providers only. This does not apply to: selected prosthetics and orthotics that do not require special skills to provide.

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

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

     WAC 388-543-2700 Prosthetics and orthotics – reimbursement methodology.

     (4) MAA evaluates and updates the maximum allowable fees for prosthetics and orthotics at least once per year, independent of legislatively authorized vendor rate increases. Rates remain effective until the next rate change.

     (5) MAA implements fee schedule changes for prosthetics and orthotics July 1 of each year. Rates remain effective until the next rate change. Reimbursement for prosthetics and orthotics is limited to HCPC/National Codes with the same level of coverage as Medicare.

     (6) Reimbursement for gender dysphoria surgery includes payment for all related prosthetics and supplies.

     WAC 388-543-2800:

     (2) MAA bases its determination about which DME and related supplies, prosthetics, orthotics, medical supplies and related services require prior authorization (PA) or expedited prior authorization (EPA) on utilization criteria (see WAC 388-543-1000 for PA and WAC 388-543-1800 for EPA). MAA 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.

     (3) MAA requires a provider to obtain a limitation extension in order to exceed the stated limits for nondurable medical equipment and medical supplies. See WAC 388-501-0165.

     (2) (4) MAA categorizes medical supplies and non-DME (MSE) as follows (see MAA's billing instructions for specific limitations):...

     (k) Urological supplies (e.g., diapers, urinary retention catheters, pant liners and doublers); and

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's Own Initiative: New 21, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 21, Amended 0, Repealed 0.

Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 21, Amended 0, Repealed 0. Effective Date of Rule: Thirty-one days after filing.

December 13, 2000

Marie Myerchin-Redifer, Manager

Rules and policies Assistance Unit

     "Artificial limb" - See "prosthetic device."

     "Augmentative communication device (ACD)" means a medical device that transmits or produces messages or symbols, either by voice output or in writing, in a manner that compensates for the impairment or disability of a client with severe expressive or language communication and comprehension disorders. The communication device may use mechanical or electrical impulses to produce messages or symbols that supplement or replace speech.      "Base year" means the year of the data source used in calculating prices.

     "By report (BR)" means a method of reimbursement for covered items, procedures, and services for which the department has no set maximum allowable fees.

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

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

     "Durable medical equipment (DME)" means 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/healthy kids" - see WAC 388-500-0005.

     "Expedited prior authorization (EPA)" means the process for obtaining authorization for selected durable medical equipment, and related supplies, prosthetics, orthotics, medical supplies and related services, in which providers use a set of numeric codes to indicate to MAA which acceptable indications/conditions/MAA-defined criteria are applicable to a particular request for DME authorization.

     "Fee-for-service (FFS)," means the general payment method MAA uses to reimburse for covered medical services provided to clients, except those services covered under MAA's managed care programs.

     "Health care financing administration common procedure coding system (HCPCS)" means a coding system established by the Health Care Financing Administration to define services and procedures.

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

     "Limitation extension" means an authorization process to exceed a coverage limitation (quantity, frequency, or duration) set in WAC, billing instructions, or numbered memoranda. Limitation extensions require prior authorization.

     "Nonreusable supplies" are disposable supplies, which are used once and discarded.

     "Manual wheelchair" - see "wheelchair - manual."

     "Medical supplies" means 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.

     "Orthotic device" or "orthotic" means 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" means an item or service which primarily serves the comfort or convenience of the client.

     "Personal computer (PC)" means any of a variety of electronic devices that are capable of accepting data and instructions, executing the instructions to process the data, and presenting the results. A PC has a central processing unit (CPU), internal and external memory storage, and various input/output devices such as a keyboard, display screen, and printer. A computer system consists of hardware (the physical components of the system) and software (the programs used by the computer to carry out its operations).

     "Power-drive wheelchair" - see "wheelchair - power."

     "Prior authorization" means a process by which clients or providers must request and receive MAA approval for certain medical equipment and related supplies, prosthetics, orthotics, medical supplies and related services, based on medical necessity, before the services are provided to clients, as a precondition for provider reimbursement. Expedited prior authorization and limitation extension are types of prior authorization. Also see WAC 388-501-0165.

     "Prosthetic device" or "prosthetic" means 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:

     (1) Artificially replace a missing portion of the body;

     (2) Prevent or correct physical deformity or malfunction; or

     (3) Support a weak or deformed portion of the body.

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

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

     "Scooter" means 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" means a pressure reducing support surface, such as foam, air, water, or gel mattress or overlay.

     "Three- or four-wheeled scooter" means 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" means 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" means the amount the provider typically charges to fifty percent or more of his or her non-Medicaid clients, including clients with other third-party coverage.

     "Warranty-wheelchair" means a warranty, according to manufacturers' guidelines, of not less than one year from the date of purchase.

     "Wheelchair - manual" means 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" means 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) The medical assistance administration (MAA) covers DME and related supplies, prosthetics, orthotics, medical supplies, related services, repairs and labor charges when all of the following apply. They must be:

     (a) Within the scope of an eligible client's medical care program (see chapter 388-529 WAC);

     (b) Within accepted medical or physical medicine community standards of practice;

     (c) Prior authorized as described in WAC 388-543-1600, 388-543-1800, and 388-543-1900;

     (d) Prescribed by a qualified provider, acting within the scope of the provider's practice. The prescription must state the specific item or service requested, diagnosis, prognosis, estimated length of need (weeks or months, not to exceed six months before being reevaluated), and quantity;

     (e) Billed to the department as the payor of last resort only. MAA does not pay first and then collect from Medicare;

     (f) Medically necessary as defined in WAC 388-500-0005. The provider or client must submit sufficient objective evidence to establish medical necessity. Information used to establish medical necessity includes, but is not limited to, the following:

     (i) A physiological description of the client's disease, injury, impairment, or other ailment, and any changes in the client's condition written by the prescribing physician, licensed prosthetist and/or orthotist, physical therapist, occupational therapist, or speech therapist; or

     (ii) Video and/or photograph(s) of the client demonstrating the impairments as well and client's ability to use the requested equipment, when applicable.

     (2) MAA evaluates a request for any equipment or devices that are listed as noncovered in WAC 388-543-1300 under the provisions of WAC 388-501-0165.

     (3) MAA evaluates a request for a service that is in a covered category, but has been determined to be experimental or investigational under WAC 388-531-0050, under the provisions of WAC 388-501-0165 which relate to medical necessity.

     (4) MAA evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions when medically necessary, under the standards for covered services in WAC 388-501-0165.

     (5) MAA 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 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.

     (6) MAA covers medical equipment and related supplies, prosthetics, orthotics, medical supplies and related services, repairs, and labor charges listed in MAA's published issuances, including Washington Administrative Code (WAC), billing instructions, and numbered memoranda.

     (7) An interested party may request MAA to include new equipment/supplies in the billing instructions by sending a written request plus all of the following:

     (a) Manufacturer's literature;

     (b) Manufacturer's pricing;

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

     (d) Any additional information the requester feels is important.

     (8) MAA bases the decision to purchase or rent DME for a client, or to pay for repairs to client-owned equipment on medical necessity.

     (9) MAA covers replacement batteries for purchased medically necessary DME equipment covered within this chapter.

     (10) MAA covers the following categories of medical equipment and supplies only when they are medically necessary, prescribed by a physician or other licensed practitioner of the healing arts, are within the scope of his or her practice as defined by state law, and are subject to the provisions of this chapter and related WACs:

     (a) Equipment and supplies prescribed in accordance with an approved plan of treatment under the home health program;

     (b) Wheelchairs and other DME;

     (c) Prosthetic/orthotic devices;

     (d) Surgical/ostomy appliances and urological supplies;

     (e) Bandages, dressings, and tapes;

     (f) Equipment and supplies for the management of diabetes; and

     (g) Other medical equipment and supplies, as listed in MAA published issuances.

     (11) MAA evaluates a BR item, procedure, or service for its medical appropriateness and reimbursement value on a case-by-case basis.

     (12) For a client in a nursing facility, MAA covers only the following when medically necessary. All other DME and supplies identified in MAA billing instructions are the responsibility of the nursing facility, in accordance with chapters 388-96 and 388-97 WAC. See also WAC 388-543-2900 (3) and (4). MAA covers:

     (a) The purchase and repair of an augmentative communication device (ACD), a wheelchair for the exclusive full-time use of a permanently disabled nursing facility resident when the wheelchair is not included in the nursing facility's per diem rate, or a specialty bed; and

     (b) The rental of a speciality bed.

     (13) Vendors must provide instructions for use of equipment; therefore, instructional materials such as pamphlets and video tapes are not covered.

     (14) Bilirubin lights are limited to rentals, for at-home newborns with jaundice.

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     (a) Have the proper business license;

     (b) Have appropriately trained qualified staff; and

     (c) Be certified, licensed and/or bonded if required, to perform the services billed to the department. Out-of-state prosthetic and orthotics providers must meet their state regulatory requirements.

     (2) MAA may reimburse qualified providers for DME and related supplies, prosthetics, orthotics, medical supplies, repairs, and related services on a fee-for-service (FFS) basis as follows:

     (a) DME providers for DME and related repair services;

     (b) Medical equipment dealers, pharmacies, and home health agencies under their medical vendor provider number for medical supplies, subject to the limitations in this section;

     (c) Licensed prosthetics and orthotics providers who are licensed by the Washington state department of health in prosthetics and orthotics. This does not apply to medical equipment dealers and pharmacies that do not require licensure to provide selected prosthetics and orthotics;

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

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

     (3) MAA terminates from Medicaid participation any provider who violates program regulations and policies, as described in WAC 388-502-0020.

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     (1) Services, procedures, treatment, devices, drugs, or the application of associated services that the department of the Food and Drug Administration (FDA) and/or the Health Care Financing Administration (HCFA) consider investigative or experimental on the date the services are provided;

     (2) Any service specifically excluded by statute;

     (3) A client's utility bills, even if the operation or maintenance of medical equipment purchased or rented by MAA for the client contributes to an increased utility bill (refer to the aging and adult services administration's (AASA) COPES program for potential coverage);

     (4) Hairpieces or wigs;

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

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

     (7) Outpatient office visit supplies, such as tongue depressors and surgical gloves;

     (8) Prosthetic devices dispensed solely for cosmetic reasons (refer to WAC 388-531-0150 (1)(d);

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

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

     (b) Saunas;    

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

     (d) Swimming pools;

     (e) Whirlpool systems, such as jacuzzies, hot tubs, or spas; or

     (f) Electrical rewiring for any reason;

     (g) Elevator systems and elevators; and

     (h) Lifts or ramps for the home; or

     (i) Installation of bathtubs or shower stalls.

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

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

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

     (c) Car seats for children under five, except for positioning car seats that are prior authorized. Refer to WAC 388-543-1700(13) for car seats;

     (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 healthcare providers (e.g., hospitals, physicians), for self care home monitoring, or emergency response systems and services (refer to AASA COPES or outpatient hospital programs for emergency response systems and services);

     (iii) Two-way radios; and

     (iv) Rental of related equipment or services;

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

     (h) Ergonomic equipment;

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

     (j) Generators;

     (k) Personal computers including laptops, computer software, printers, computer accessories (such as anti-glare shields, backup memory cards), and computer equipment other than specified in WAC 388-543-2200;

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

     (m) Room fresheners/deodorizers;

     (n) Bidet or hygiene systems, paraffin bath units, and shampoo rings;

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

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

     (q) Wheeled reclining chairs, lounge and/or lift chairs (e.g., geri-chair, posture guard, or lazy boy).

     (11) Personal and comfort items that do not meet the DME definition, including but not limited to the following:

     (a) Bathroom 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) Bedding items, such as bed pads, blankets, mattress covers/bags, pillows, pillow cases/covers and sheets;

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

     (d) Clothing and accessories, such as coats, gloves (including wheelchair gloves), hats, scarves, slippers, and socks;

     (e) Clothing protectors and other protective cloth furniture coverings;

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

     (g) Diverter valves for bathtub;

     (h) Eating/feeding utensils;

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

     (j) Health club memberships;

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

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

     (m) Impotence devices;

     (n) Insect repellants;

     (o) Massage equipment;

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

     (q) 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) Page turners;

     (s) Radio and television;

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

     (u) Toothettes and toothbrushes, waterpics, and peridontal devices whether manual, battery-operated, or electric.

     (12) Certain wheelchair features and options are not considered by MAA to be medically necessary or essential for wheelchair use. This includes, but is not limited to, the following:

     (a) Attendant controls (remote control devices);

     (b) Canopies, including those 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) Identification devices (such as labels, license plates, name plates);

     (e) Lighting systems;

     (f) Speed conversion kits; and

     (g) Tie-down restraints, except where medically necessary for client-owned vehicles.

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     (a) The provider meets all of the conditions in WAC 388-502-0100; and

     (b) MAA does not include the item/service for which the provider is requesting reimbursement in other reimbursement rate methodologies. Other methodologies include, but are not limited to, the following:

     (i) Hospice providers' per diem reimbursement;

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

     (iii) Managed care plans' capitation rate; and

     (iv) Nursing facilities' per diem rate.

     (2) MAA sets maximum allowable fees for DME and related supplies, prosthetics, orthotics, medical supplies and related services using available published information, such as:

     (a) Commercial databases for price comparisons;

     (b) Manufacturers' catalogs;

     (c) Medicare fee schedules; and

     (d) Wholesale prices.

     (3) MAA may adopt policies, procedure codes, and/or rates that are inconsistent with those set by Medicare if MAA determines that such actions are in the best interest of its clients.

     (4) MAA updates the maximum allowable fees for DME and supplies and prosthetic/orthotic devices no more than once per year, unless otherwise directed by the legislature. MAA may update the rates for different categories of medical equipment and prosthetic/orthotic devices at different times during the year.

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

     (6) MAA's maximum payment for medical equipment and supplies is the lesser of either of the following:

     (a) Providers' usual and customary charges; or

     (b) Established rates, except as provided in subsection (7)(a) of this section.

     (7) If a client is eligible for both Medicare and Medicaid, the following apply:

     (a) MAA requires a provider to accept Medicare assignment before any Medicaid reimbursement;

     (b) If the service provided is covered by Medicare and Medicaid, MAA pays:

     (i) The deductible and coinsurance up to Medicare's allowed amount or MAA's allowed amount, whichever is less; or

     (ii) For services that are not covered by Medicare but are covered by MAA, if medically necessary.

     (8) MAA may pay for medical services rendered to a client only when MAA is the payor of last resort.

     (9) MAA does not cover medical equipment and/or services provided to a client who is enrolled in a MAA-contracted managed care plan, but did not use one of the plan's participating provider.

     (10) See WAC 388-543-2100, 388-543-2500, 388-543-2700, and 388-543-2900 for other reimbursement methodologies.

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     (2) MAA's reimbursement for covered DME and related supplies, prosthetics, and orthotics includes all of the following:

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

     (b) Fitting and set-up; and

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

     (3) MAA requires a provider to furnish to MAA clients only new equipment that includes full manufacturer and dealer warranties.

     (4) MAA requires a dispensing provider to include a warranty on equipment for one year after the date MAA considers rented equipment to be purchased, as provided under WAC 388-543-1700(3).

     (5) MAA charges the dispensing provider for any costs it incurs to have another provider repair equipment if all of the following apply:

     (a) Any DME that MAA considers purchased according to WAC 388-543-1700 requires repair during the applicable warranty period;

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

     (c) The client still needs the equipment.

     (6) MAA charges the dispensing provider fifty percent of the total amount MAA paid toward rental and eventual purchase of the first equipment if the rental equipment must be replaced during the warranty period. All of the following must apply:

     (a) Any medical equipment that MAA considers purchased according to WAC 388-543-1700 requires replacement during the applicable warranty period;

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

     (c) The client still needs the equipment.

     (7) Purchase orders:

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

     (i) Dies;

     (ii) Loses medical eligibility;

     (iii) Becomes covered by a hospice agency; or

     (iv) Becomes covered by an MAA managed care plan. Refer to subsection (7)(c) of this section.

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

     (c) A client may become a managed care plan client before MAA completes the purchase of prescribed medical equipment. If this occurs:

     (i) MAA rescinds the purchase order until the managed care primary care provider (PCP) evaluates the client; then

     (ii) MAA 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; then

     (iii) The managed care plan's applicable reimbursement policies apply to the purchase or rental of the equipment.

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     (a) High cost;

     (b) Potential for utilization abuse;

     (c) Narrow therapeutic indication; and

     (d) Safety.

     (2) MAA requires providers to obtain prior authorization for certain items and services. This includes, but is not limited to, the following:

     (a) Augmentative communication devices (ACDs);

     (b) Certain by report (BR) DME and supplies as specified in MAA's published issuances, including billing instructions and numbered memoranda;

     (c) Blood glucose monitors requiring special features;

     (d) Certain equipment rentals and certain prosthetic limbs, as specified in MAA's published issuances, including billing instructions and numbered memoranda;

     (e) Decubitus care products and supplies;

     (g) Decubitus care mattresses, including flotation or gel mattress, if the provider fails to meet the criteria in WAC 388-543-1900;

     (g) Equipment parts and labor charges for repairs or modifications and related services;

     (h) Hospital beds, if the provider fails to meet the requirements in WAC 388-543-1900;

     (i) Low air loss flotation system, if the provider fails to meet the requirements in WAC 388-543-1900;

     (j) Orthopedic shoes and selected orthotics;

     (k) Osteogenic stimulator, noninvasive, if the provider fails to meet the requirements in WAC 388-543-1900;

     (l) Positioning car seats for children under five years of age;

     (m) Transcutaneous electrical nerve stimulators, if the provider fails to meet the requirements in WAC 388-543-1900;

     (n) Wheelchairs, wheelchair accessories, wheelchair modifications, air, foam, and gel cushions, and repairs;

     (o) Wheelchair-style shower/commode chairs;

     (p) Other DME not specifically listed in MAA's published issuances, including billing instructions and numbered memoranda, and submitted as a miscellaneous procedure code; and

     (q) Limitation extensions.

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Reviser's note: The typographical error in the above section occurred in the copy filed by the agency and appears in the Register pursuant to the requirements of RCW 34.08.040.
NEW SECTION
WAC 388-543-1700   When MAA covers rented DME.   (1) MAA's reimbursement amount for rented durable medical equipment (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.

     (2) MAA requires a dispensing provider to ensure the DME rented to a MAA client is both of the following:

     (a) In good working order; and

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

     (3) MAA considers rented equipment to be purchased after twelve months' rental unless one of the following apply:

     (a) The equipment is restricted as rental only; or

     (b) Other MAA published issuances state otherwise.

     (4) MAA rents, but does not purchase, certain medically necessary equipment for clients. This includes, but is not limited to, the following:

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

     (b) Electric breast pumps.

     (5) MAA's minimum rental period for covered DME is one day.

     (6) If a fee-for-service (FFS) client becomes a managed care plan client, both of the following apply:

     (a) MAA stops paying for any rented equipment on the last day of the month preceding the month in which the client becomes enrolled in the managed care plan; and

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

     (7) MAA stops paying for any rented equipment effective the date of a client's death. MAA prorates monthly rentals as appropriate.

     (8) For a client who is eligible for both Medicaid and Medicare, MAA pays only the client's coinsurance and deductibles. MAA 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.

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

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     (2) For prior authorization requests, MAA 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. MAA does not accept general standards of care or industry standards for generalized equipment as justification.

     (3) When MAA receives an initial request for prior authorization, the prescription(s) for those items or services cannot be older than three months from the date MAA receives the request.

     (4) MAA authorizes BR items that require prior authorization and are listed in MAA's published issuances, including billing instructions and numbered memoranda, only if medical necessity is established and the provider furnishes all of the following information to MAA:

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

     (b) The cost or charge for the item;

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

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

     (5) MAA 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.

     (6) MAA prior authorizes payment for repair and modification of client-owned equipment only when the criteria in subsection (1) of this section are met. Requests for repairs must include the information listed in subsection (5) of this section.

     (7) MAA does not reimburse for purchase, rental, or repair of medical equipment that duplicates equipment the client already owns or rents. If the requesting provider makes such a request, MAA requires the provider to submit for prior authorization and explain the following:

     (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 those medical needs.

     (8) MAA informs the provider and the client of a less costly alternative from MAA's manufacturers' literature on file when an MAA denial of a request is based on a less costly, equally effective alternative.

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

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

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     (2) MAA 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 MAA published DME-related billing instructions. The authorization number must be used when the provider bills MAA.

     (3) The written or telephonic request for prior authorization process must be used when a situation does not meet the criteria for a selected DME code or a requested rental exceeds the limited rental period indicated.

     (4) Upon request, a provider must provide documentation to MAA showing how the client's condition met the criteria for EPA in subsection (2) of this section.

     (5) MAA may recoup any payment made to a provider under this section if the provider did not follow the expedited authorization process and criteria. Refer to WAC 388-502-0100.

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     (2) The following apply when MAA determines that a wheelchair is medically necessary for six months or less:

     (a) If the client lives at home, MAA rents a wheelchair for the client; or

     (b) If the client lives in a nursing facility, the nursing facility must provide a house wheelchair as part of the per diem rate paid by AASA.

     (3) MAA considers 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. MAA determines the type of manual wheelchair based on the following:

     (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 up to three hundred pounds; 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 over three hundred pounds; 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 above categories of wheelchairs.

     (4) MAA considers a power-drive wheelchair when the client's medical needs cannot be met by a less costly means of mobility. The prescribing physician must certify that the client can safely and effectively operate a power-drive wheelchair and that the client meets all of the following conditions:

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

     (b) A power-drive wheelchair will provide the client the only means of independent mobility; or

     (c) A power-drive wheelchair will enable a child to achieve age-appropriate independence and developmental milestones.

     (d) All other circumstances will be considered based on medical necessity and on a case-by-case basis.

     (e) The following additional information is required for a three or four-wheeled power-drive scooter/cart:

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

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

     (5) MAA considers the power-drive wheelchair to be the client's primary chair when the client has both a power-drive wheelchair and a manual wheelchair.

     (6) In order to consider purchasing a wheelchair, MAA requires the provider to submit the following information from the prescribing physician, physical therapist, or occupational therapist:

     (a) Specific medical justification for the make and model of wheelchair requested;

     (b) Define the degree and extent of the client's impairment (such as stage of decubitus, severity of spasticity or flaccidity, degree of kyphosis or scoliosis); and

     (c) Documented outcomes of less expensive alternatives (aids to mobility) that have been tried by the client.

     (7) In addition to the basic wheelchair, MAA may consider wheelchair accessories or modifications that are specifically identified by the manufacturer as separate line item charges. The provider must submit specific medical justification for each line item, with the modification request.

     (8) MAA considers wheelchair modifications to a medically necessary wheelchair when the provider submits all of the following with the modification request:

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

     (b) The modification requested; and

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

     (9) MAA may consider wheelchair repairs to a medically necessary wheelchair; the provider must submit to MAA the make, model, and serial number of the wheelchair for which the repairs are requested.

     (10) MAA may cover two wheelchairs, a manual wheelchair and a power-drive wheelchair, for a noninstitutionalized client in certain situations. One of the following must apply:

     (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 radii;

     (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;

     (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; the manual wheelchair would allow the caregiver to transport the client in a standard automobile or van. In these cases, MAA 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 neither available, practical, nor possible for financial or other reasons.

     (iii) All other circumstances will be considered on a case-by-case basis, based on medical necessity.

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     (a) The client's medical needs;

     (b) Product quality;

     (c) Cost; and

     (d) Available alternatives.

     (2) For HCPCS codes for wheelchair rentals and wheelchair accessories (e.g., cushions and backs), MAA uses the Medicare fees that are current on April 1 of each year.

     (3) For state-assigned procedure codes, including those listed as BR, for wheelchairs and wheelchair accessories, MAA's maximum allowable reimbursement is based on a percentage of the manufacturer's list price in effect on January 31 of the base year, or the invoice for the specific item. This applies to the following:

     (a) For basic standard wheelchairs, sixty-five percent;

     (b) For add-on accessories and parts, eighty-four percent;

     (c) For upcharge modifications and cushions, eighty percent;

     (d) For all other manual wheelchairs, eighty percent; and

     (e) For all other power-drive wheelchairs, eighty-five percent.

     (4) MAA determines rental reimbursement for categories of manual and power-driven wheelchairs based on average market rental rates or Medicare rates.

     (5) MAA evaluates and updates the wheelchair fee schedule once per year.

     (6) MAA implements wheelchair rate changes on April 1 of the base year, and the rates are effective until the next rate change.

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     (2) MAA requires a provider to submit a prior authorization request for ACDs. The request must be in writing and contain all of the following information:

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

     (b) An assessment by a licensed speech pathologist of the client's verbal capabilities. The pathologist must be knowledgeable about selecting ACDs that meet the client's needs;

     (c) If the client has a physical disability, condition, or impairment that requires equipment, such as a wheelchair, or a device to be specially adapted to accommodate an ACD, an assessment by the prescribing physician, licensed occupational therapist or physical therapist; and

     (d) Documented evaluations and/or trials of each ACD that the client has tried. This includes less costly types/models, and the effectiveness of each device in promoting the client's ability to communicate with health care providers, caregivers, and others.

     (3) MAA requires the provider to show or the client to demonstrate all of the following:

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

     (b) The client has the cognitive ability to effectively and independently utilize the equipment; and

     (c) With the ADC, the client will be able to do all of the following:

     (i) Communicate with the personal physician about the medical condition, complaint, ailment, or symptoms;

     (ii) Communicate with the personal caregiver about both urgent medical needs and routine personal care needs; and

     (iii) Communicate with medical personnel who provide emergency services, rehabilitative care, and other therapeutic treatment.

     (4) MAA covers ACDs only once every two years for a client who meets the criteria in subsection (3) of this section. MAA does not approve a new or updated component, modification, or replacement model for a client whose ACD is less than two years old. MAA may make exceptions to the criteria in this subsection based strictly on a finding of unforeseeable and significant changes to the client's medical condition. The prescribing physician is responsible for justifying why the changes in the client's medical condition were unforeseeable.

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     (2) MAA considers a wheelchair-style shower commode chair only if the client meets both of the following:

     (a) Is able to propel the equipment; and

     (b) Has special positioning needs that cannot be met by a caster-style chair.

     (3) All other circumstances will be considered on a case-by-case basis, based on medical necessity.

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     (a) MAA initially authorizes a maximum of two months rental for a short-term need. Upon request, MAA may allow limitation extensions as medically necessary;

     (b) MAA determines rental on a month-to-month basis if a client's prognosis is poor;

     (c) MAA considers a purchase if the need is for more than six months;

     (d) If the client continues to have a medical need for a hospital bed after six months, MAA may approve rental for up to an additional six months. MAA considers the equipment to be purchased after a total of twelve months' rental.

     (2) MAA considers a manual hospital bed the primary option when the client has full-time caregivers.

     (3) MAA considers a full electric hospital bed only if the client meets all of the following criteria:

     (a) The client's medical need requires the client to be positioned in a way that is not possible in a regular bed;

     (b) 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);

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

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

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

     (4) All other circumstances for hospital beds will be considered on a case-by-case basic, based on medical necessity.

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     (a) "Other durable medical equipment (other DME)" means all durable medical equipment, excluding wheelchairs and related items.

     (b) "Pricing cluster" means a group of discounted manufacturers' list prices and/or dealer's costs for brands/models of other DME that MAA uses to calculate the reimbursement rate for a procedure code that does not have a fee established by Medicare. MAA uses the discounted manufacturer list price for a brand/model unless that price is not available.

     (2) MAA establishes reimbursement rates for purchased other DME.

     (a) For HCPCS procedure codes that have a Medicare rate established for a new purchase, MAA uses the rate that is in effect on January first of the year in which MAA sets the reimbursement.

     (b) For all other procedure codes, MAA uses a pricing cluster to establish the rate.

     (3) Establishing a pricing cluster and reimbursement rates.

     (a) In order to make up a pricing cluster for a procedure code, MAA determines which brands/models of other DME its clients most frequently use. MAA obtains prices for these brands/models from manufacturer catalogs or commercial databases. MAA may change or otherwise limit the number of brands/models included in the pricing cluster, based on the following:

     (i) Client medical needs;

     (ii) Product quality;

     (iii) Introduction of new brands/models;

     (iv) A manufacturer discontinuing or substituting a brand/model; and/or

     (v) Cost.

     (b) If a manufacturer list price is not available for any of the brands/models used in the pricing cluster, MAA calculates the reimbursement rate at the manufacturer's published cost to providers plus a thirty-five percent mark-up.

     (c) For each brand used in the pricing cluster, MAA discounts the manufacturer's list price by twenty percent.

     (i) If six or more brands/models are used in the pricing cluster, MAA calculates the reimbursement rate at the seventieth percentile of the pricing cluster.

     (ii) If five brands/models are used in the pricing cluster, MAA establishes the reimbursement rate at the fourth highest discounted list price, as described in (b) of this subsection.

     (iii) If four brands/models are used in the pricing cluster, MAA establishes the reimbursement rate at the third highest discounted list price, as described in (b) of this subsection.

     (iv) If three brands/models are used in the pricing cluster, MAA establishes the reimbursement rate at the third highest discounted list price, as described in (b) of this subsection.

     (v) If two or fewer brands/models are used in the pricing cluster, MAA establishes the reimbursement rate at the highest discounted list price, as described in (b) of this subsection.

     (4) Rental reimbursement rates for other DME.

     (a) MAA sets monthly rental rates at one-tenth of the purchase reimbursement rate as it would be calculated as described in subsections (2) and (3) of this section.

     (b) MAA sets daily rental rates at one-three hundredth of the purchase reimbursement rate as it would be calculated as described in subsections (2) and (3) of this section.

     (5) MAA annually evaluates and updates reimbursement rates for other DME.

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     (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.

     (2) MAA does not cover prosthetics dispensed for purely cosmetic reasons.

     (3) MAA covers a replacement prosthesis only when the purchase of a replacement prosthesis is less costly than repairing or modifying a client's current prosthesis.

     (4) MAA 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, MAA requires the client's caregiver to be responsible. MAA authorizes extensive maintenance that the manufacturer recommends be performed by an authorized dealer.

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     (2) MAA's reimbursement for a prosthetic or orthotic includes the cost of any necessary molds.

     (3) MAA's hospital reimbursement rate includes any prosthetics and/or orthotics required for surgery and/or placed during the hospital stay.

     (4) MAA evaluates and updates the maximum allowable fees for prosthetics and orthotics at least once per year, independent of scheduled legislatively authorized vendor rate increases. Rates remain effective until the next rate change.

     (5) Reimbursement for prosthetics and orthotics is limited to HCPC/National Codes with the same level of coverage as Medicare.

     (6) Reimbursement for gender dyphoria surgery includes payment for all related prosthetics and supplies.

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     (2) MAA bases its determination about which DME and related supplies, prosthetics, orthotics, medical supplies and related services require prior authorization (PA) or expedited prior authorization (EPA) on utilization criteria (see WAC 388-543-1000 for PA and WAC 388-543-1800 for EPA). MAA 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.

     (3) MAA requires a provider to obtain a limitation extension in order to exceed the stated limits for nondurable medical equipment and medical supplies. See WAC 388-501-0165.

     (4) MAA categorizes medical supplies and non-DME (MSE) as follows (see MAA's billing instructions for specific limitations):

     (a) Antiseptics and germicides;

     (b) Bandages, dressings, and tapes;

     (c) Blood monitoring supplies;

     (d) Braces, belts, and supportive devices;

     (e) Decubitus care products;

     (f) Ostomy supplies;

     (g) Pregnancy-related testing kits and nursing equipment;

     (h) Supplies associated with osteogenesis stimulators;

     (i) Supplies associated with transcutaneous electrical nerve stimulators (TENS);

     (j) Syringes and needles;

     (k) Urological supplies (e.g., diapers, urinary retention catheters, pant liners, and doublers); and

     (l) Miscellaneous supplies.

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     (a) Medicare fee schedule; or

     (b) Manufacturers' catalogs and commercial databases for price comparisons.

     (2) MAA evaluates and updates the maximum allowable fees for MSE as follows:

     (a) For HCPCS MSE codes, MAA considers the current Medicare fee schedule;

     (b) For all MSE with state-assigned procedure codes, when the legislature mandates a vendor rate increase or decrease.

     (c) MAA sets the maximum allowable fees for new MSE using one of the following:

     (i) Medicare's fee schedule; or

     (ii) For those items without a Medicare fee, commercial databases to obtain all brands to make up MAA's pricing cluster. MAA establishes the fee for products in the pricing cluster by using the lesser of either:

     (A) Eighty-five percent of the average manufacturer's list price; or

     (B) One hundred twenty-five percent of the average dealer cost.

     (d) All the brands for which MAA obtains pricing information make up MAA's pricing cluster. However, MAA may limit the number of brands included in the pricing cluster if doing so is in the best interests of its clients. MAA considers all of the following:

     (i) A client's medical needs;

     (ii) Product quality;

     (iii) Cost; and

     (iv) Available alternatives.

     (3) MAA's nursing facility per diem rate includes any reusable and disposable medical supplies that may be required for a nursing facility client. MAA may reimburse the following medical supplies separately for a client in a nursing facility:

     (a) Medical supplies or services that replace all or parts 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; 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; and

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

     (4) MAA considers decubitus care products to be included in the nursing facility per diem rate and does not reimburse for these separately.

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     The following section of the Washington Administrative Code is repealed:

WAC 388-87-110

Durable medical equipment -- Prosthetic devices.

© Washington State Code Reviser's Office