WSR 02-16-054

PERMANENT RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Medical Assistance Administration)

[ Filed August 1, 2002, 3:55 p.m. ]

Date of Adoption: July 25, 2002.

Purpose: To change the name augmentative communication device (ACD) to speech generating device (SGD) to reflect Medicare terminology and new federal HIPAA (Health Insurance Portability and Accountability Act) definitions; to clarify criteria for covered SGDs; and to bring department policy regarding SGDs into closer alignment with new federal HIPAA regulations.

Citation of Existing Rules Affected by this Order: Amending WAC 388-543-1000, 388-543-1100, 388-543-1300, and 388-543-2200.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.530.

Adopted under notice filed as WSR 01-21-106 on October 23, 2001, and supplemental notice WSR 02-10-115 on April 30, 2002.

Changes Other than Editing from Proposed to Adopted Version: For rules proposed as WSR 01-21-106 and 02-10-115; describing any changes other than editing from proposed version filed as WSR 02-10-115 to adopted version.

The following changes were made as a result of public comments:

WAC 388-543-1000:

"The following definitions and abbreviations and those found in WAC 388-500-0005 apply to this chapter. Defined words and phrases are bolded the first time they are used in the text."

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

"Limitation extension means an authorization a process for requesting and approving covered services and reimbursement that to exceeds a coverage limitation (quantity, frequency, or duration) set in WAC, billing instructions, or numbered memoranda. Limitation extensions require prior authorization."

WAC 388-543-1300

"(1) MAA pays only for DME and related supplies, medical supplies and related services that are medically necessary, listed as covered in this chapter, and meet the definition of DME and medical supplies as defined in WAC 388-543-1000 and prescribed per WAC 388-543-1100 and 388-543-1200."

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 4, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.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

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, 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 0, Amended 4, Repealed 0.
Effective Date of Rule: Thirty-one days after filing.

July 25, 2002

Brian Lindgren, Manager

Rules and Policies Assistance Unit

3002.8
AMENDATORY SECTION(Amending WSR 01-01-078, filed 12/13/00, effective 1/13/01)

WAC 388-543-1000   Definitions for durable medical equipment (DME) and related supplies, prosthetics, and orthotics, medical supplies and related services.   The following definitions and abbreviations and those found in WAC 388-500-0005 apply to this chapter. ((Defined words and phrases are bolded the first time they are used in the text.))

"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)) -See "speech generating device (SGD).

"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 prepaid managed care programs.

"Health care financing administration common procedure coding system (HCPCS)" means 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).

"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)) a process ((to)) for requesting and approving covered services and reimbursement that exceeds 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.

"Speech generating device (SGD)" means 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)."

"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.

[Statutory Authority: RCW 74.08.090, 74.09.530. 01-01-078, 388-543-1000, filed 12/13/00, effective 1/13/01.]


AMENDATORY SECTION(Amending WSR 01-01-078, filed 12/13/00, effective 1/13/01)

WAC 388-543-1100   Scope of coverage and coverage limitations for DME and related supplies, prosthetics, orthotics, medical supplies and related services.   The federal government deems durable medical equipment (DME) and related supplies, prosthetics, orthotics, and medical supplies as 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)((/healthy kids)) program. The department may reduce or eliminate coverage for optional services, consistent with legislative appropriations.

(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 in this chapter 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 speech generating device (SGD), 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.

[Statutory Authority: RCW 74.08.090, 74.09.530. 01-01-078, 388-543-1100, filed 12/13/00, effective 1/13/01.]


AMENDATORY SECTION(Amending WSR 01-01-078, filed 12/13/00, effective 1/13/01)

WAC 388-543-1300   Equipment, related supplies, or other nonmedical supplies, and devices that are not covered.   (1) MAA pays only for DME and related supplies, medical supplies and related services that are medically necessary, listed as covered in this chapter, and meet the definition of DME and medical supplies as defined in WAC 388-543-1000 and prescribed per WAC 388-543-1100 and 388-543-1200.

(2) MAA 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 orthotic as defined in WAC 388-543-1000 and are prescribed per WAC 388-543-1100 and 388-543-1200.

(3) MAA considers all requests for covered DME, related supplies and services, medical supplies, prosthetics, orthotics, and related services and noncovered equipment, related supplies and services, supplies and devices, under the provisions of WAC 388-501-0165 ((which relate to medical necessity)). When MAA considers that a request does not meet the requirement 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.

(4) 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 does not apply if the services and equipment are ((required under the EPSDT/healthy kids program,)):

(a) Included as part of a managed care plan service package((,));

(b) Included in a waivered program((, or));

(c) Part of one of the Medicare programs for qualified Medicare beneficiaries; or

(d) Requested for a child who is eligible for services under the EPSDT program. MAA reviews these requests according to the provisions of chapter 388-534 WAC.

(5) Excluded services and equipment include, but are not limited to:

(((1))) (a) Services, procedures, treatment, devices, drugs, or the application of associated services that the department of the Food and Drug Administration (FDA) and/or the Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA) consider investigative or experimental on the date the services are provided;

(((2))) (b) Any service specifically excluded by statute;

(((3))) (c) 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))) (d) Hairpieces or wigs;

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

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

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

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

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

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

(((b))) (ii) Saunas;

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

(((d))) (iv) Swimming pools;

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

(((f))) (vi) Electrical rewiring for any reason;

(((g))) (vii) Elevator systems and elevators; and

(((h))) (viii) Lifts or ramps for the home; or

(((i))) (ix) Installation of bathtubs or shower stalls.

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

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

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

(((c))) (iii) 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))) (iv) Cleaning brushes and supplies, except for ostomy-related cleaners/supplies;

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

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

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

(((ii))) (B) 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))) (C) Two-way radios; and

(((iv))) (D) Rental of related equipment or services;

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

(((h))) (viii) Ergonomic equipment;

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

(((j))) (x) Generators;

(((k) Personal computers including laptops,))

(xi) Computer software other than speech generating, printers, and computer accessories (such as anti-glare shields, backup memory cards)((, and computer equipment other than specified in WAC 388-543-2200));

(((l))) (xii) Computer utility bills, telephone bills, Internet service, or technical support for computers or electronic notebooks;

(xiii) Any communication device that is useful to someone without severe speech impairment (e.g., cellular telephone, walkie-talkie, pager, or electronic notebook);

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

(((m))) (xv) Room fresheners/deodorizers;

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

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

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

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

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

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

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

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

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

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

(((g))) (vii) Diverter valves for bathtub;

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

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

(((j))) (x) Health club memberships;

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

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

(((m))) (xiii) Impotence devices;

(((n))) (xiv) Insect repellants;

(((o))) (xv) Massage equipment;

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

(((q))) (xvii) 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))) (xviii) Page turners;

(((s))) (xix) Radio and television;

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

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

(((12))) (l) 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))) (i) Attendant controls (remote control devices);

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

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

(((d))) (iv) Identification devices (such as labels, license plates, name plates);

(((e))) (v) Lighting systems;

(((f))) (vi) Speed conversion kits; and

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

[Statutory Authority: RCW 74.08.090, 74.09.530. 01-01-078, 388-543-1300, filed 12/13/00, effective 1/13/01.]

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.
AMENDATORY SECTION(Amending WSR 01-01-078, filed 12/13/00, effective 1/13/01)

WAC 388-543-2200   ((Augmentative communication)) Speech generating devices (((ACD))) (SGD).   (1) MAA considers all requests for speech generating devices (SGDs) on a case-by-case basis ((for augmentative communication devices (ACDs) for the purpose of appropriately relaying medical information.

(2))). The SGD requested must be for a severe expressive speech impairment, and the medical condition must warrant the use of a device to replace verbal communication (e.g., to communicate medical information).

(2) In order for MAA to cover an SGD, the SGD must be a speech device intended for use by the individual who has a severe expressive speech impairment, and have one of the following characteristics. For the purposes of this section, MAA uses the Medicare definitions for "digitized speech" and "synthesized speech" that were in effect as of April 1, 2002. The SGD must have:

(a) Digitized speech output, using pre-recorded 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) MAA requires a provider to submit a prior authorization request for ((ACDs)) SGDs. The request must be in writing and contain all of the following information:

(a) A detailed description of the client's therapeutic history((;)), including, at a minimum:

(i) The medical diagnosis;

(ii) A physiological description of the underlying disorder;

(iii) A description of the functional limitations; and

(iv) The prognosis for improvement or degeneration.

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

(c))) (SLP) that includes all of the following:

(i) 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)) SGD, an assessment by the prescribing physician, licensed occupational therapist or physical therapist; ((and))

(((d))) (ii) Documented evaluations and/or trials of each ((ACD)) SGD 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));

(iii) The current communication impairment, including the type, severity, language skills, cognitive ability, and anticipated course of the impairment;

(iv) An assessment of whether the client's daily communication needs could be met using other natural modes of communication;

(v) A description of the functional communication goals expected to be achieved, and treatment options;

(vi) Documentation that the client's speaking needs cannot be met using natural communication methods; and

(vii) Documentation that other forms of treatment have been ruled out.

(c) The provider ((to show or the client to demonstrate)) has shown or has demonstrated all of the following:

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

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

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

(d) A prescription for the SGD from the client's treating physician.

(4) MAA may require trial-use rental. All rental costs for the trial-use will be applied to the purchase price.

(5) MAA covers ((ACDs)) SGDs 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)) SGD can be repaired or modified. 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.

(6) 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 MAA, MAA evaluates the request based on medical necessity and the requirements in this section. The request for an SGD must meet the authorization requirements in this section.

[Statutory Authority: RCW 74.08.090, 74.09.530. 01-01-078, 388-543-2200, filed 12/13/00, effective 1/13/01.]

Washington State Code Reviser's Office