Infusion Pumps

Definitions

Affiliate: A person who directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, the ordering physician or consultant.

Physiatrist: A physician who specializes in physical medicine or who possesses specialized knowledge of rehabilitation and who is certified by the American Board of Physical Medicine and Rehabilitation (ABPMR).

Prosthetic: An artificial device, as defined by Medicare, to replace a missing or nonfunctional body part.

Stationary and Ambulatory Infusion Pumps

Codes: E0779 (rental only), E0780 (purchase only), E0781 (rental or purchase)

Authorization is not required.

Documentation of the following is required:

The physician's order must include the length of need (number of days per month and/or total number of months), diagnosis, name of drug, frequency of administration, and a copy of the treatment plan.

Enteral and Parenteral Nutrition Infusion Pumps

Codes: B9000, B9002, B9004, B9006, E0791

Authorization is required for maintenance service or for repairs to patient-owned pumps when the cost of the parts and labor exceeds $1,000.

Implantable (E0782, E0783, E0786)

Implantable infusion pumps always require Service Authorization before they are provided.

Documentation regarding the medical condition and the medical need for these pumps is required.

The physician’s order must include the length of need (number of days per month and/or total number of months), diagnosis, name of drug, frequency of administration, and a copy of the treatment plan.

Enteral nutrition claims must include a product description or the four-character code that matches an item on the DHS Enteral Nutrition Price List. The description should be submitted in Loop 2400, element SV101-7 of the 837P transaction. Ensure the product description corresponds exactly to a product listed on the DHS Enteral Nutrition Price List for the following codes: B4157 – B4162 and B4149 – B4155.

Mechanical Stretching Devices 

Mechanical stretching devices, or extension and flexion devices, are used for the treatment of joint contractures in lower and upper extremities. These devices are intended to maintain or restore range of motion and replace some therapy-directed sessions through consistent and frequent joint mobilization in an outpatient setting or in the home.  Dynamic splinting systems referred to as low-load prolonged-duration stretch (LLPS) devices are spring-loaded, adjustable devices used to treat joint contractures. LLPS devices are designed to maintain low-load prolonged stretch while members are asleep or at rest.

PrimeWest Health covers mechanical stretching devices or dynamic splinting systems for eligible PrimeWest Health members effective May 1, 2025.

Members must either be:

• Suffering from joint stiffness and not responding to physical or occupational therapy during the subacute injury or postoperative period (for example, at least three weeks but less than four months after injury or surgery); or
• Have a documented history of motion stiffness or loss in a joint, have had a surgery or procedure done to improve motion to that joint, and are in the acute postoperative period following a second or subsequent surgery or procedure.

Covered Services

Codes: E1800, E1802 – E1805, E1807, E1808, E1810, E1812 – E1815, E1820, E1822, E1823, E1825 – E1830, E1840

Dynamic splinting systems for extension and/or flexion are covered for ankles (E1815, E1822, and E1823), elbows (E1800, E1803, and E1804), fingers (E1825 to E1827), forearms (E1802), knees (E1810, E1812 to E1814), shoulders (E1840), toes (E1828 to E1830), or wrists (E1805, E1807, and E1808).

Authorization

Authorization is always required. PrimeWest Health does not cover static progressive stretch (SPS) or patient-actuated serial stretch (PASS) devices.
Documentation for authorization requests must include the following:

• Member's diagnosis
• Order
• A face-to-face evaluation by a physical or occupational therapist
• Clinical history of member's joint stiffness and prior treatments, including physical or occupational therapy, any surgeries, and other procedures
• Treatment plan, including baseline measurements of range of motion limitations

Miscellaneous Codes

Use the most specific Healthcare Common Procedure Coding System (HCPCS) code for the item being dispensed. Do not use miscellaneous codes for the sole purpose of trying to receive higher reimbursement.

PrimeWest Health accepts the following miscellaneous HCPCS codes:

Procedure Code	Description	Usage	Prior Authorization Requirements
A4335	Incontinence supply, miscellaneous	Use for supplies (with no specific HCPCS code) relating to urinary or fecal incontinence.	None
A4421	Ostomy supply; miscellaneous	Use for any miscellaneous supplies for ostomies in the colon, ileum, abdomen, or similar	None
A4649	Surgical supply, miscellaneous	Use for miscellaneous wound care supplies and items related to surgical procedures.	Over $400
A6512	Compression burn garment, not otherwise classified	Use for burn garments not classified by other compression supplies	Over $400
A6519	Gradient compression garment, not otherwise specified, for nighttime use, each	Use for nighttime-use garments not specified by other compression supplies	Over $400
A6549	Gradient compression garment, not otherwise specified, for daytime use, each	Use for daytime-use garments not specified by other compression supplies	Over $400
A6584	Gradient compression wrap with adjustable straps, not otherwise specified	Use for wraps not specified by other compression supplies	Over $400
A6593	Accessory for gradient compression garment or wrap with adjustable straps, not otherwise specified	Use for garments or wraps not specified by other compression supplies	Over $400
A6609	Gradient compression bandaging supply, not otherwise specified	Use for bandaging supplies not specified by other compression supplies	Over $400
A9900	Miscellaneous durable medical equipment (DME) supply, accessory, and/or service component of another HCPCS code	Use for parts, accessories, or service components for DME that require authorization	Over $400
A9901	DME delivery, set up, and/or dispensing service component of another HCPCS code	Use for service components for authorized or covered DME	Authorization is not required for phototherapy light service fee under A9901 U3
A9999	Miscellaneous DME supply or accessory, not otherwise specified (NOS)	Use for an accessory or an added-on part to a piece of DME that has no code. Not used for the entire piece of equipment, just a part of it.	Over $400
B9998	Enteral supplies, not otherwise classified	Use for supplies relating to enteral nutrition.	None
B9999	Parenteral supplies, not otherwise classified	Use for supplies relation to parenteral nutrition.	None
E1399	DME, miscellaneous	Use for DME	Over $400
K0108	Wheelchair component or accessory, not otherwise specified	Use for accessories or components for mobility devices	Over $400
L0999	Addition to spinal orthosis, not otherwise specified	Use for spinal orthotic additions that are not otherwise specified	Authorization required if cost is greater than $3,000 allowed
L1499	Spinal orthosis, not otherwise specified	Use for spinal orthoses or components that are not otherwise specified	Authorization required if cost is greater than $3,000 allowed
L2999	Lower extremity orthoses, not otherwise specified	Use for lower extremity orthoses or components that that are not otherwise specified	Authorization required after limit of 4 (2 sets) per calendar year or if the allowed amount is more than $3,000
L3999	Upper limb orthosis, not otherwise specified	Use for upper limb orthoses or components that that are not otherwise specified	Authorization required after limit of 4 (2 sets) per calendar year or if the allowed amount is more than $3,000
L5999	Lower extremity prosthesis, not otherwise specified	Use for lower extremity prostheses or components that that are not otherwise specified	Authorization required if cost is greater than $3,000 allowed
L7499	Upper extremity prosthesis, not otherwise specified	Use for upper extremity prostheses or components that that are not otherwise specified	Authorization required if cost is greater than $3,000 allowed
L8048	Unspecified maxillofacial prosthesis, by report, provided by a nonphysician	Use for medically necessary custom facial prostheses	Authorization required if cost is greater than $3,000 allowed
S8189	Tracheostomy supply, not otherwise classified	Use for supplies relating to tracheostomy	None
T5999	Supply, NOS	Use for disposable supplies that do not fit into any of the other more specific miscellaneous supply codes.	None
V2629	Prosthetic eye, other type	Use for medically necessary custom eye prostheses	None

Billing Miscellaneous Codes

When billing for multiple products that are different but require the use of the same miscellaneous HCPCS code, use the correct miscellaneous code and modifier for the first line item, and add the 76 modifier to each additional line using the same miscellaneous HCPCS code. If billing multiple units of the same product, bill using the correct miscellaneous code and modifier and indicate the number of units dispensed.

Add the description for each line with a miscellaneous code.

The following miscellaneous HCPCS/procedure codes will be automatically priced if the correct description of the product is entered on the claim:

1. A7520, A7521, and B4088 require the use of the NU modifier for auto pricing at the fee schedule rate. For auto pricing of specialized items, enter the appropriate HCPCS code with the U3 modifier and the long description.
2. A4335, A4421, A4649, A9999, B9998, and S8189 require the use of the NU modifier and the long description for auto pricing.

Miscellaneous Products

Augmentative Communication Devices (E2500 – E2599)

Authorization is always required.

An augmentative communication device is a device dedicated to transmitting or producing messages or symbols in a manner that compensates for the impairment and disability of a member with severe expressive communication disorders (e.g., communication picture books, communication charts and boards, and mechanical/electronic devices). Devices requested for the sole purpose of education will not be approved.

1. Augmentative communication devices can be obtained from medical equipment and supply providers and manufacturers of augmentative communication devices.
2. Technical services, such as repairs, are covered.
3. Documentation sent with request should include the following:
   1. A description of the current medical status and history
   2. An assessment of the verbal and physical capabilities in relation to need and use of an augmentative communication device (electronic and non-electronic)
   3. A detailed description of the therapeutic history in the areas of physical and occupational therapy and speech-language pathology and the nature, frequency, and duration of total therapeutic history provided to the member. Speech-language treatment approaches in relation to the need and use of an augmentative communication device must be detailed.
   4. An explicit evaluation of each augmentative communication device or method of communication tried by the member and information on the effectiveness of each device. All parameters of device selection must be addressed (i.e., interactive ability in all situational contexts; school, home, community, vocational, work, and social environments). A trial period of at least four weeks with the requested device must be documented.
   5. A detailed description of the member’s ability to use the proposed device, including speed and accuracy. Situation references dependent upon the mobility level of the member must be addressed (i., How will the device be adapted to meet the needs of a member who uses a walker? Is the communication device less obtrusive than other methods when mobility levels are considered?). Empirical data regarding the trial period of use with the device is required (i.e., frequency of device use in various settings).
   6. A description of the level of communication initiation with the selected communication device and whether or not the equipment is used accurately and spontaneously. If the pattern of initiation is different from past history, provide an explanation and justification for the change.
   7. A detailed description and plan for the proposed nature, frequency, and duration of therapeutic intervention in relation to the augmentative communication device. Include all therapeutic intervention necessary.

Non-Covered Services Relating to Augmentative Communication Devices

1. Augmentative communication/speech-generating devices requested for the sole purpose of education
2. Environmental control devices such as switches, control boxes, or battery interrupters
3. Modification, construction, programming, or adaptation of communication systems
4. Repairs, cleaning, or other services for devices that are not dedicated communication devices
5. Upgrading to new technology that is not proven to be medically necessary
6. Replacing devices based on the manufacturer’s recommended replacement schedule (i.e., every five years)
7. Facilitated communication: a technique by which a “facilitator” provides physical and other supports in an attempt to assist a person with a significant communication disability to point to pictures, objects, and printed works or letters (PrimeWest Health does not cover facilitated communication by any provider)
8. Personal computers, laptop computers, electronic tablet such as iPods or iPads, and other personal media players that are not dedicated communication devices
9. Telephones
10. Carry cases when a mounting device has been purchased

Blood Pressure Monitors (A4660, A4663, A4670)

Blood pressure monitoring devices and supplies are covered for members who require frequent monitoring of blood pressure or as part of dialysis. 

• One sphygmomanometer device is covered every five years. 
• One automatic blood pressure monitor is covered every three years. 
• One blood pressure cuff is covered annually for member-owned equipment. A blood pressure cuff cannot be billed with the primary device. 

Breast Pumps (E0602, E0603, E0604)

Overview

Breast pumps are devices used to extract milk from the breast of a nursing birthing person for infant feeding when the birthing person cannot be present at feeding time or when the infant is too sick or too weak to suck. A breast pump may be provided prior to delivery if the ordering provider documents a medical necessity, such as anticipated return to work or school shortly after delivery or other medical consideration.

Refer to Obstetrics and Gynecology (OB/GYN) Services for more information on reproductive health policy. 

Eligible Providers

The following providers are eligible to provide breast pumps: 

• Hospitals
• Durable Medical Equipment (DME) suppliers
• Pharmacies

Providers must meet provider criteria, including accreditation, for TPL insurance or for Medicare-approved providers to assist members for whom PrimeWest Health is not the primary payer.

PrimeWest Health quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.

Eligible Members

Breast pumps and breast pump supplies are covered for eligible Minnesota Health Care Programs (MHCP) members when ordered by a physician, certified nurse midwife, or nurse practitioner for any nursing birthing person experiencing separation from their infant because of work, school, illness, or a medical reason, or for an infant who is too sick or weak to suck.  

Covered Services

Manual breast pumps (E0602)  and electric breast pumps (E0603) are for purchase only. Inform members that breast pumps are a personal care item that cannot be shared by mothers. They can be used for future pregnancies. Purchase of breast pumps is limited to one personal electric breast pump and one manual breast pump per pregnancy. Bill with modifier NU.

Hospital-grade breast pumps (E0604) are rental only. The rental period of hospital-grade pumps is three months. Prior authorization is required for additional months if a member has medical necessity for a hospital-grade pump beyond the first three months. This item always requires Service Authorization. Documentation should include why E0602 or E0603 cannot be used for the member.

Bill with modifier RR. Bill accessory kits for hospital-grade breast pumps with HCPCS code A9999.

HCPCS Code	Code Definition	Quantity Limit
A4281	Tubing for breast pump, replacement	2 per year
A4282	Adapter for breast pump, replacement	2 per year
A4283	Cap for breast pump bottle, replacement	2 per year
A4284	Breast shield and splash protector for use with breast pump, replacement	2 per year
A4285	Polycarbonate bottle for use with breast pump, replacement	2 per year
A4286	Lock ring for breast pump, replacement	2 per year
A4287	Disposable collection and storage bag for breast milk, any size, any type, each	200 per month
A4288	Valve for breast pump, replacement	2 units per year

 

HCPCS codes A4281 to A4286 are only reimbursable when the specific replacement part of the breast pump no longer functions properly. HCPCS codes A4281 to A4286 are not separately reimbursable within the same month of purchase of HCPCS codes E0602 and E0603.

Noncovered Services

PrimeWest Health does not cover the following: 

• Baby weight scales
• Cleaning supplies for breast pumps
• Clothing or other products that permit hands-free pump operation
• Nursing bras, bra pads, breast shells, nipple shields, and other similar products
• Replacement parts when the original part of the breast pump is functional
• Travel bags and other accessories for transporting breast pumps and supplies 

Refer to Noncovered Services in the Billing the Member (Recipient) section of the MHCP Provider Manual for more information about conditions required to bill the member. 

Billing

Providers are responsible for coordinating services. Refer to Billing Policy Overview in the Providers Basics section of the MHCP Provider Manual for general billing information.

• Bill using MN–ITS 837P Professional. Refer to the Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices MN–ITS user guide for general billing requirements and guidance when submitting claims.
• If the birthing person is eligible, bill breast pumps and breast pump supplies using the birthing person’s PrimeWest Health member ID number.
• If the birthing person is ineligible, bill breast pumps and breast pump supplies using the infant’s PrimeWest Health member ID number. Include the infant’s name, date of birth, and gender if billing under the infant’s PrimeWest Health member ID number.
• Use modifier NU for purchases of manual and electric breast pumps.
• Use modifier RR for rentals of hospital-grade breast pumps.
• Bill using HCPCS code A9999 for accessory kits for hospital-grade breast pumps.

Cochlear Device (L8614, L8619)

Authorization is always required. Provide all information to demonstrate medical need.

Continuous Passive Motion (CPM) Machines (E0935, E0936)

Authorization is always required. Documentation should include the following:

1. Nature of injury and/or surgery, affected joint
2. Date surgery performed
3. Amount of time prescribed for CPM use and frequency
4. For E0935, knee range of motion (ROM) and flexion in degrees
5. Type of rehabilitation ordered and member’s compliance

For continued use after 23 days from surgery, provide documentation about the following:

1. Has range of motion improved?
2. Current flexion in degrees for E0935
3. Use of CPM by member, for how many hours and frequency of use
4. Any other rehabilitation ordered?

EarPopper

Code: E1399 NU

EarPopper Home Version is covered when prescribed by a physician for members over age 3 with otitis media with effusion or eustachian tube dysfunction who are unable to independently perform the Politzer maneuver.

Enema System

Code: A4459

A manual pump-operated enema system requires a Service Authorization before being provided to a member age 2 and over. This is not covered for members under 2 years old.

Provide documentation indicating the following:

• Prescription by a physician
• Member’s condition for which the manual pump-operated enema system is needed (neurogenic bowel dysfunction)
• Indication of any fecal incontinence, chronic constipation, and/or time-consuming bowel management procedures
• Other conservative bowel management alternatives tried and their effectiveness.

If a Service Authorization is approved, the limit is purchase of up to two per year.

Oral Appliances for Sleep Disorder

Codes: E0485, E0486

Authorization is always required. Provide documentation of medical need for the appliance and treatment tried with outcome.

Dental providers billing for a sleep apnea appliance should also refer to the Dental Providers Billing for Sleep Apnea Appliance section in Dental.

Piercing Device, Skin (E0620)

Authorization is always required. Provide documentation regarding the medical need and why a lancet cannot be used instead.

QR Powder/Nosebleed QR/Wound Seal Powder

Code: A4649 NU

WoundSeal Powder, QR Powder for Lacerations, QR Powder for Kid’s Cuts and Scrapes, QR Powder for Nosebleeds, and Gentle Formulation QR Powder for Nosebleeds are covered without an authorization when prescribed by a physician for members with bleeding disorders, including bleeding disorders caused by use of anticoagulants.

The claim must include a diagnosis code specific to the bleeding disorder. Up to 4 units may be dispensed in anticipation of future need. It is not necessary to open packaging; providers may dispense a box of two or four applications. 1 unit = 1 application.

Syringes and Needles

Codes: A4206 – A4209, A4212, A4213, A4215

Syringes are covered for members who require medication administration via a syringe. Documentation must demonstrate medical necessity for the quantity dispensed. Sterile needles (A4215) are covered when needles are dispensed without syringes or when dispensed with a syringe code that does not include needles when medically necessary. The member’s diagnosis is required. Noncoring needles (A4212) are covered for members who require minimization of skin tissue trauma and cannot tolerate traditional needles. Do not bill HCPCS code A4212 in addition to HCPCS code A4220.

Insulin syringes are categorized under HCPCS code S8490. 

Sharps Disposal Containers

Members who self-administer medications using syringes may receive sharps disposal containers. Bill using A4211 and modifier U3 along with appropriate pricing information as outlined in Claims & Payment.

Drug Infusion Supplies

Codes: A4220 – A4223, A4244 – A4248, A4305, A4306, E0776, E0780 – E0783, E0786, K0601 – K0605

Drug infusion supplies are covered for members who require medications from infusion devices. Implantable infusion pumps (E0782, E0783, E0786) are covered with authorization for members who require regular and precise administration of medications. Infusion devices are surgically attached to members to provide long-term continuous administration of medications for indications such as cancer, cerebral or spinal cord injuries, pulmonary arterial hypertension, and chronic and severe pain in members who have successfully trialed opioid or nonopioid medications by the same method of treatment. Devices are covered one per five years. Supplies (A4220 to A4223) are covered for authorized infusion pumps. Documentation must include the member’s diagnosis and clinical history, item to be dispensed, medications, frequency of administration, consideration of less costly alternatives, and a trial demonstrates the member is able to use the device. Authorization is always required.

Intravenous poles (E0776) are covered for members who require infusion for medication, fluids, or nutrition from solution bags. Do not bill HCPCS code E0776 when dispensing an intravenous pole or holder that is attached to a mobility device.
Alcohol or peroxide (A4244) and alcohol wipes (A4245) are covered for members who require injections or sterilization of equipment. Betadine or pHisoHex solution (A4246) and swabs or wipes (A4247) are only covered as a medical supply when dispensed by an approved dialysis equipment provider for members receiving dialysis for end-stage renal disease (ESRD). Chlorhexidine antiseptic (A4248) is noncovered as a medical supply. HCPCS codes A4246 and A4247 for non-dialysis indications and HCPCS code A4248 for any indication must be billed by a pharmacy as a drug.

Batteries

Codes: A4601, A4602

Lithium-ion batteries for nonprosthetic use (A4601) and for external infusion pumps (A4602) are covered for member-owned equipment when the original battery no longer functions. Document in the medical record that the original item is no longer functional.

Slings, Splints, and Straps

Codes: A4467, A4565, A4566, A4570, A4580, A4590

Belts, straps, sleeves, garments, or coverings (A4467), slings (A4565), splints (A4570), and shoulder slings or vests (A4566) are covered for members who require support for an impaired or injured body part. Cast supplies (A4580) and special casting materials (A4590) are noncovered as they are included in payment for the service.

Weighted Blankets or Vests

Code: E1399 NU

Weighted blankets or vests are covered for members who have developmental disabilities, including autism spectrum disorders. The function of the weighted blankets is to provide proprioception (deep pressure), which has a calming effect that allows people with developmental disabilities to interact with their environment. Documentation needs to include relevant diagnoses of the member and evaluation performed by an occupational therapist that justifies medical necessity.

Protective Helmets

Codes: A8000 – A8004

Protective helmets, including prefabricated and custom fabricated items and soft interface replacements, are covered for members at risk of head injury due to a medical condition such as seizures or developmental disability. Most members over age 2 can be served with one protective helmet per year. Members under age 2 may require more frequent replacements. Documentation must explain why a prefabricated helmet does not suffice.

Mobility Devices

Manual wheelchairs, power operated vehicles, and power wheelchairs assist individuals with mobility-related disabilities to complete activities of daily living (ADL) in their homes and communities. They are a covered service for eligible PrimeWest Health members who meet criteria for medical necessity.

Mobility device vendors must be enrolled as medical equipment providers. Providers must be able to provide support services such as the following:

1. Emergency services
2. Delivery and setup
3. Repairs
4. Warranty service (a copy of the warranty must be given to the member and a copy kept in the provider’s records)
5. Education and ongoing assistance with the use of the wheelchair or scooter

Providers must have skilled and knowledgeable service personnel, with an adequate inventory of replacement parts to provide timely, on-site (in member’s home or work environment) mobility device services and repairs.

Providers must have loaner chairs available for the member whose chair requires repair. If the member’s chair is customized and unique to his/her specific needs, PrimeWest Health does not expect providers to have an equivalent chair on hand. If providers do not have an equivalent loaner chair available, they may provide a rental chair to accommodate the member’s needs while repairing the customized chair.

PrimeWest Health will reimburse providers for the rental of a mobility device. To bill, use code K0462 and include the Healthcare Common Procedure Coding System (HCPCS) code of the item being repaired or the item dispensed as a rental if different and less costly in the claim notes field. If the rental is longer than one month, providers must provide documentation as to why the repair is taking longer than a month. Explain the additional circumstances and rental time needed. PrimeWest Health does not pay for repairs of rental or loaner chairs.

Third Party Liability (TPL) and Medicare

Providers must meet any provider criteria, including accreditation for third party insurance or for Medicare in order to assist members for whom PrimeWest Health is not the primary payer.

Medicare requires providers dispensing Group 2 single power option wheelchairs/any multiple power option wheelchairs to employ a Rehabilitative Engineering and Assisted Technology Society of America (RESNA)-certified Assistive Technology Professional (ATP) specializing in wheelchairs who is directly involved in the wheelchair selection for the member. Providers assisting members who have both Medicare and Medicaid (dual eligibles) must comply with this Medicare rule.

Providers who do not meet Medicare requirements must refer and document the referral of dual eligible members to Medicare providers when Medicare is determined to be the appropriate payer for services and supplies and equipment.

If Medicare downcodes a mobility device, PrimeWest Health must make payment based on the downcoded Medicare explanation of benefits (EOB), regardless of any prior authorization. Providers may choose to offer only Medicare-covered mobility devices to dual eligible members.

Eligible Members – Criteria for All Covered Mobility Devices

Mobility devices are covered for eligible PrimeWest Health members with a mobility limitation that significantly impairs their ability to participate in one or more mobility-related ADLs and the mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. Daily living refers to activities such as toileting, feeding, grooming, education, working, or job training. The mobility device must:

1. Enable the member to participate in mobility related ADLs
2. Be appropriate to the member’s needs and abilities

A “backup” manual chair may be covered if needed to allow the member to access medical care or essential services in the community, or when the member’s power chair includes custom molded seating such that the member cannot be served with a loaner or rental chair during repairs.

When a power wheelchair is purchased for a member who already has a manual wheelchair, PrimeWest Health will assume that the power wheelchair is replacing the manual wheelchair. Repairs to the manual wheelchair will not be covered unless documentation is submitted that the manual wheelchair meets criteria as a backup wheelchair.

Documentation submitted with previous authorization requests will be considered when determining if criteria are met for a backup wheelchair.

To be considered custom molded seating, the wheelchair must require significant customization to maintain the member in an appropriate position. The use of supports alone does not constitute customization.

PrimeWest Health follows InterQual^® criteria for medical necessity determinations for wheelchairs and other mobility devices.

Covered Services

1. Specific mobility devices, options, and accessories
2. Manual wheelchairs
3. Power operated vehicles
4. Power wheelchairs
5. Wheelchair options and accessories
6. Custom molded and prefabricated seating systems
7. Wheelchairs in long-term care facilities (LTCFs)

Specific Mobility Devices, Options, and Accessories

Providers must be prepared to submit additional documentation of medical necessity beyond what is typically required, when asked.

Standard options and accessories for manual wheelchairs include the following:

1. Calf rests/pads
2. Fixed height arm rests (fixed, swingaway, or detachable)
3. Foot rests and footplates (fixed, swingaway, or detachable)
4. Hand rims with or without projections
5. Wheel lock assemblies

Non-standard options and accessories for manual wheelchairs may include the following:

1. Adjustable height arm rests
2. Anti-rollback device
3. Elevating leg rests
4. Head rest extensions
5. Nonstandard seat frames (standard is 15 – 19” wide by 15 – 19” deep)
6. One-arm drive attachments
7. Positioning accessories
8. Push activated power assist
9. Safety belts/straps
10. Skin protection seat cushions

The following codes may not be filled within 30 days of initial issue of a manual wheelchair:

Manual Wheelchair Accessory Codes
E0967	E2210	E2226	K0044	K0070
E0981	E2220	K0015	K0045	K0071
E0982	E2221	K0017	K0046	K0072
E0995	E2222	K0018	K0047	K0077
E1011	E2223	K0019	K0050
E2205	E2224	K0042	K0052
E2206	E2225	K0043	K0069

Backup Manual Wheelchairs

• A “backup” manual chair may be covered for members with a powered mobility device. Requests will be reviewed individually to determine medical necessity. Clearly state that the request is for a backup chair when requesting authorization.
• When a power wheelchair is purchased for a member who already has a manual wheelchair, PrimeWest Health will assume that the power wheelchair is replacing the manual wheelchair. Repairs to the manual wheelchair will not be covered unless documentation is submitted that the manual wheelchair meets criteria as a backup wheelchair.
• Documentation submitted with previous authorization requests will be considered when determining if criteria are met for a backup wheelchair.
• A basic manual wheelchair, transport chair, or rollabout chair may be covered if needed to allow the member to access medical care in the community, even if not needed for other activities of daily living.
• Documentation must clearly justify why other, less-costly manual wheelchairs, will not meet the member’s needs. The wheelchair must require significant customization to maintain the member in an appropriate position to be considered custom-molded. The use of supports does not constitute a custom-molded seating system or custom-molded back.

Manual Wheelchairs (K0001 – K0004, E1229)

No authorization is required for purchase or rental unless noted.

Special Manual Wheelchairs (E1161, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, K0005, K0009)
Authorization is always required. PrimeWest Health follows InterQual^® criteria for medical necessity determinations.

Roll about/Transport chairs (E1031, E1037 – E1039)
No authorization is required for rental or purchase. Provide documentation of the following:

1. The member is not expected to be able to self-propel a manual or power wheelchair in the next five years
2. The member has needs that cannot be met by a less costly manual wheelchair
3. The proposed chair has casters of at least five inches in diameter and is specifically designed to meet the needs of ill, injured, or otherwise impaired individuals

Power Operated Vehicles (E1230, K0800 – K0802, K0806 – K0808, K0812)

Power operated vehicles are covered if the member meets medical necessity criteria. PrimeWest Health follows InterQual^® criteria for medical necessity determinations. Standard equipment includes the following:

1. Battery or batteries required for operation
2. Single mode battery charger
3. Weight appropriate upholstery and seating system
4. Tiller steering
5. Non-expandable controller with proportional response to input
6. Complete set of tires
7. All accessories needed for safe operation

Options and accessories provided at the time of initial issue of a power operated vehicle are not separately billable.

Power Wheelchairs (K0813 – K0898)

A power wheelchair may be covered if the member has a specific medical need that cannot be met with a less costly alternative. PrimeWest Health follows InterQual^® criteria for determining medical necessity.

Standard equipment includes the following:

1. All types of tires and wheels
2. Any back width
3. Any seat width and depth
4. Weight specific components required by member’s weight capacity
5. Battery charger
6. Fixed swing-away or detachable:
   1. Footrests/foot platform
7. Non-adjustable armrests with arm pad
8. Non-elevating leg rests with/without calf pad
9. Lap belt or safety belt
10. Non expandable controller
11. Standard integrated or remote proportional joystick

Non-standard options or accessories may include the following:

1. Adjustable height arm rests
2. Elevating leg rests
3. Manual fully reclining back option
4. Power tilt
5. Power recline
6. Seat elevator
7. Shoulder harness/straps or chest straps/vest
8. Skin protection seat cushions, position accessories
9. Standing feature

Do not bill the following codes within 30 days of initial issue of a power wheelchair:

Power Wheelchair Accessory Codes
E0971	E2369	E2386	E2395	K0042
E0978	E2370	E2387	E2396	K0043
E0981	E2374	E2388	K0015	K0044
E0982	E2375	E2389	K0017	K0045
E0995	E2376	E2390	K0018	K0046
E1225	E2381	E2391	K0019	K0047
E2366	E2382	E2392	K0020	K0051
E2367	E2384	E2393	K0037	K0052
E2368	E2385	E2394	K0041	K0098

Do not bill E2377 when used with a Group 1 or Group 2 no power option power wheelchair, and do not bill K0040 when used with a Group 1 or Group 2 power wheelchair.

Standard power wheelchairs with dates of service on or after January 1, 2011, must be rented following standard capped rental rules per the CMS supplier manual. This includes the codes in the range K0813 – K0831 and K0898.

Complex rehabilitative power wheelchairs (HCPCS codes K0835 – K0843 and K0848 – K0864) and options/ accessories furnished for use with a complex rehabilitative power wheelchair can be either rented or purchased.

Group 4 power wheelchairs (PWCs) (K0868 – K0886) have added capabilities that are not needed for use in the home. Therefore, if these wheelchairs are provided, they will be denied as not reasonable and necessary for Medicare payment and will be assessed for medical necessity using Medical Assistance (Medicaid).

Wheelchair Options and Accessories

Wheelchair options and accessories are covered if they are medically necessary and address a specific medical need of the member. The following list of options and accessories is not all-inclusive; many additional options and accessories may be covered if medically necessary.

1. One arm drive attachments (E0958) are covered if:
   1. The member meets the criteria for a manual wheelchair, but is unable to use both arms or at least one lower extremity to safely propel the manual wheelchair
   2. A trial demonstrated the member has the strength, stamina, and cognitive ability to propel the wheelchair using the one arm drive attachment

2. Push activated power assist (E0986) is covered (authorization required) if the member:

1. Has expressed an unwillingness to operate a power wheelchair
2. Has one of the following:

1. Was self-propelling in a manual wheelchair but no longer has sufficient upper extremity function to self-propel a manual wheelchair
2. Was self-propelling in a manual wheelchair but has weakness or repetitive motion stress to the shoulders or upper arms

Documentation must include the following:

1. An assessment of the distance the member is expected to need to operate the manual wheelchair
2. A trial sufficient to demonstrate the member is able to operate the manual wheelchair for that distance
3. An estimate indicating how long the push activated power manual wheelchair is expected to meet the member’s mobility needs

3. Power tilt (E1002) is covered (authorization required) if the member:
   1. Meets criteria for a wheelchair
   2. Has one of the following needs:
      1. Is at risk for pressure ulcers and is unable to perform a functional weight shift
      2. Has a fixed hip angle
      3. Has increased or excess muscle tone/spasticity related to a medical diagnosis which impairs his/her ability to tolerate the fully upright sitting position for significant periods of time
   3. Is able to independently operate the power tilt system

4. Power recline (E1003 – E1005) is covered (authorization required) if the member:
   1. Meets criteria for a power wheelchair
   2. Is able to independently operate the power recline system
   3. Has one of the following:

1. Is unable to tolerate a full upright position due to a medical condition that impairs his/her ability to tolerate the fully upright sitting position for significant periods of time
2. Uses intermittent catheterization
3. Has edema and is unable, for physical or other reasons, to periodically transfer from the wheelchair to elevate the legs

If a reclining seating system is approved because a member has edema, manual or power elevating leg rests must be requested.

5. Power tilt and recline seating systems, with or without power elevating legs rests (E1006 – E1008) are covered (authorization required) if the member:
   1. Meets criteria for a power wheelchair
   2. Is able to independently operate the power tilt and recline system
   3. Has more than one of the following:

1. A fixed hip angle
2. Increased or excess muscle tone/spasticity related to a medical diagnosis that impairs his/her ability to tolerate the fully upright sitting position for significant periods of time
3. Is at high risk for pressure ulcers and is unable to perform a functional weight shift
4. Uses intermittent catheterization
5. Edema and is unable, for physical or other reasons, to periodically transfer from the wheelchair

If a reclining seating system is approved because a member has edema, manual or power elevating leg rests must be requested.

6. Mechanical leg elevation systems (E1009) are covered if the member:
   1. Meets criteria for a wheelchair
   2. Has one of the following:

1. Has a medical condition which prevents 90 degrees of knee flexion
2. A treatment program to decrease flexion contractures of the knee
3. Leg edema which cannot be treated by an edema control wrap, a recline feature as part of the wheelchair, and is unable, for physical or other reasons, to periodically independently transfer from the wheelchair to elevate legs

7. Power leg elevation systems (E1010, E1012) are covered (E1012 requires an authorization) if the member:

1. Meets criteria for a power wheelchair
2. Has one of the following:

1. A medical condition which prevents 90 degree of knee flexion
2. A treatment program to decrease flexion contractures of the knee
3. Leg edema which cannot be treated by an edema control wrap, a recline feature as part of the wheelchair, and is unable, for physical or other reasons, to periodically independently transfer from the wheelchair to elevate the legs
4. Is able to independently operate the power leg elevation system

8. Manual, fully, or semi-reclining backs (E1014, E1225, E1226) are covered (authorization required) if the member has one of the following:
   1. At high risk for pressure ulcers and is unable to perform a function weight shift
   2. Uses intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair
   3. Is unable to tolerate a full upright position due to a medical condition
9. Wheelchair transportation or transit securement systems (E1022, E1023) are covered if the member meets ALL of the following criteria:
   1. Criteria for a mobility device; and
   2. Is at risk for unsafe transfers in private vehicles or public transportation; and
   3. Is dependent for transfers and transitions in transportation
10. Retractable or removable mounting hardware (E1028, E1023 – E1034) is covered if the member needs accessories to be manually moved or removed from the wheelchair mount.
11. Gear reduction drive wheels (E2227) are covered (authorization required) if the member:
    1. Meets criteria for a manual wheelchair
    2. Is at risk for weakness or repetitive motion injury to the arms or shoulders
12. Dynamic seating frame (E2295) is covered when:
    1. The requested dynamic seating frame is made by the same manufacturer as the requested pediatric wheelchair
    2. The requested pediatric wheelchair independently meets all criteria for medical necessity and least costly appropriate equipment
    3. The member does not require tilt-in-space or reclining back
    4. The member is able to engage in some hip or knee extension
13. Seat elevation feature (E2298) is covered (authorization required) if the member has one of the following:
    1. Must routinely transfer between uneven surfaces and the surfaces cannot be adjusted and the seat elevation feature allows the member to independently transfer
    2. Cannot be safely transferred using a patient lift or standing transfer but can safely transfer with the seat elevation feature
    3. The seat elevation feature has been demonstrated to allow the member to independently access areas in the home necessary for completion of ADLs (cupboards, closets, et)

Documentation must specify where uneven transfers will be needed in the member’s home, or where in the home safe transfers cannot be made using a patient lift/standing transfer.

A seat elevation feature is not covered when requested to allow the member to socialize with peers.

If a wheelchair with a seat elevation feature is approved and purchased for a member, the provider must obtain documentation from the member acknowledging that the seat elevation function may affect future requests for PCA or home care services before dispensing and billing for this item. This documentation must be made available to PrimeWest Health staff upon request.

12. Standing feature (manual: E2230; power: E2301) is covered (authorization required) if:
    1. The member meets the InterQual^® criteria for a stander
    2. PrimeWest Health has not purchased a stander for the member in the previous three years
    3. The standing function has been demonstrated to allow the member to independently access areas in the home necessary for completion of ADLs (cupboards, closets, et)

A standing feature is not covered when requested to allow the member to socialize at eye level with peers.

If a wheelchair with a standing feature is approved and purchased for a member, the provider must obtain documentation from the member acknowledging PrimeWest Health will not pay for future repairs to a stander and the standing function may affect future requests for PCA or home care services before dispensing and billing for this item. This documentation must be made available to PrimeWest Health staff upon request.

13. Alternative Interface Devices (E2312, E2321 – E2330, E2373) is covered if the member:

1. Meets criteria for a power wheelchair and cannot safely operate the wheelchair using a hand- or chin- operated standard proportional joystick
2. Can safely operate the wheelchair using the alternative device

14. Power wheelchair attendant control (E2331) is covered if the member:
    1. Meets criteria for a mobility device but is unable to operate a manual or power wheelchair
    2. Requires a power wheelchair or lacks a caregiver able to propel a manual chair
    3. Has a caregiver willing and able to operate the power wheelchair and assist the member

15. Wheelchair component or accessory, NOS (K0108)

Miscellaneous items are covered if medically necessary or if required for the functioning of other covered items. For example, if a high mount footrest is needed because the chair has a power or manual tilt, the high mount bracket is covered.

Custom Molded and Prefabricated Custom Seating Systems

Custom Molded Seating Systems

Authorization is always required for professional services associated with custom molded seating systems. Include a statement and certification number to verify the provider is certified by the American Board for Certification of Orthotics, Prosthetics & Pedorthics (ABCOP) or by RESNA with the authorization request.

Code: E2610 – Power wheelchair seat cushion also requires authorization

Authorization is always required.

Bill labor and material costs associated with fabricating an individually made sitting support spinal orthoses to PrimeWest Health using one of the following HCPCS codes:

1. E2609: Seat module molded to fit a member, custom fabricated for attachment to wheelchair base
2. E2609, E2617: Seat and back sections molded as one piece, custom fabricated for attachment to wheelchair base
3. E2609, E2617; for repairs: Repair to custom seating systems. Detail the cost of material. For DOS before January 1, 2009, use modifier RP; for dates of service (DOS) on or after January 1, 2009, use modifier RB.
4. K0739: Repairs to seating systems, per 15 minutes labor. Clearly state in the documentation that the repairs are for a seating system and not for the wheelchair.

Prefabricated Seating Systems

Bill using codes: E2605 – E2608, E2613 – E2316, E2620 – E2621, and K0669. Use K0108 when billing a head support attached to the prefabricated seating system. Payment for a head support includes mounting hardware.

Wheelchairs in Long-Term Care Facilities (LTCFs)

PrimeWest Health follows InterQual^® criteria for wheelchairs in LTCFs.

Intermediate Care Facilities for the Developmentally Disabled  (ICF/DD) coverage

Wheelchair purchases and rentals are not included in the intermediate care facility for people who are developmentally disabled (ICF/DD) per diem.

SNF per diem coverage

• Standard wheelchairs (HCPCS code: K0001) are included in the nursing facility per diem.
• All other wheelchairs (including tilt-in-space) are billable outside of the nursing facility per diem if they are necessary for the continuous care and exclusive use by a member. The member must also meet any of the policy criteria for their requested chair.

Facilities must exhaust other options for meeting a member’s needs, such as non-permanent positioning items, before requesting authorization for a wheelchair.

Authorization is required for the purchase of wheelchair seating devices, headrests, and additions/modifications to the seating system regardless of the amount billed.

Authorization for a power wheelchair will only be considered if it allows the member to experience inclusion and integration in the long-term care facility. All coverage criteria for a power wheelchair must be met.

Wheelchair cushions for prevention and treatment of skin pressure areas, including cushions used on patient owned wheelchairs, are not covered. These items are included in the facility per diem.

When a wheelchair is approved for a member, all medically necessary parts and accessories of the wheelchair are covered except skin protection cushions.

For member-owned wheelchairs in nursing facilities, repairs are covered if the chair would be approved outside the facility per diem. All repairs to wheelchairs in nursing facilities require authorization.

Replacement of worn batteries, battery chargers, wheels, tires/arm pads is not considered a repair.

Follow authorization request guidelines for repairs, and include the following information:

1. State “patient-owned wheelchair, living in long-term care (LTC)” in the “Notes” field or on an attachment
2. The original wheelchair authorization number, if available
3. If PrimeWest Health did not authorize the original purchase of the wheelchair/if the wheelchair was purchased prior to admission to the nursing facility, include documentation to support medical necessity
4. Bill using place of service (POS) code 31 and modifier U3.

Medicare does not cover the rental, purchase, or repair of mobility devices when the member is living in an LTCF. Providers must follow PrimeWest Health authorization and billing procedures. It is not necessary to bill Medicare before billing PrimeWest Health.

Non-Covered Services

Mobility devices are not covered in the following circumstances:

1. Power mobility devices if requested solely for the purpose of community outings such as attending social activities
2. Mobility devices requested to meet behavioral needs rather than mobility needs
3. Mobility devices requested solely for use in a public school if the device can be covered through an individualized education plan (IEP)
4. “Backup” devices if requested in case of equipment malfunction, unless the member’s power chair has custom molded seating such that the member cannot be served by a loaner or rental chair
5. Mobility devices designed for sports or recreational purposes
6. Wheelchairs with stair climbing ability, electronic balance, or ability to elevate the seat by balancing on two wheels
7. Home modifications
8. Lever-activated wheel drive accessories (E0988)
9. Options and accessories to convert a manual chair to a power chair (E0983 – E0984)
10. Adult power mobility devices (power wheelchairs or power operated vehicles) not reviewed by Medicare’s Pricing, Data Analysis, and Coding (PDAC) contractor or reviewed by the PDAC contractor and found not to meet the definition of a specific power mobility device. To determine the correct HCPCS code for a power mobility device, access the Durable Medical Equipment Coding System (DMECS) Product Classification List.

Authorization

1. Required Authorization
2. Authorization Requests for Purchase/Rental
3. Repair/Modification Authorization Requests

Required Authorization

Authorization is always required under the following circumstances:

1. All mobility device purchases and rentals except:

1. Standard wheelchairs (K0001, K0002, K0003, K0004, and E1229) rentals after three months
2. Roll about and transport chairs (E1031, E1037, E1038, and E1039) rentals after three months

2. Modifications to an existing wheelchair when the cost of the parts and labor exceeds $1,000
3. Repairs or replacement of parts/accessories if the submitted combined charges for parts and labor are $1,000 or more
4. Repairs or replacement of parts/accessories that are less than 365 days old
5. Miscellaneous parts billed with HCPCS code K0108 when the submitted charge for the part is $400 or more, regardless of the submitted combined charges for repairs or modifications
6. Professional services associated with custom molded seating systems
7. Custom molded seating systems and accessories as indicated above
8. All mobility devices purchases, rentals, and repairs when the member lives in a nursing facility

Authorization Requests for Purchase/Rental

Manual Wheelchairs, Power Operated Vehicles and Group 1 or Group 2 No Power Option Wheelchairs
Authorization requests for members with progressive diseases or conditions must include an assessment by a licensed/certified medical professional of the effects of the disease’s progress on the member’s ability to use the requested mobility device and an estimate indicating how long the requested mobility device is expected to meet the member’s mobility needs. Medical professional includes physical therapist (PT), occupational therapist (OT), or physician with training in rehabilitation wheelchair evaluations.

Group 2, 3, 4, or 5 Single or Multiple Power Option Power Wheelchairs
Authorization requests must include a functional assessment by a licensed/certified medical professional (PT, OT, or physician with training in rehabilitation wheelchair evaluations).

Mobility Devices for Members under Age 21
Authorization requests must include an assessment by a licensed/certified medical professional (PT, OT, or physician with training in rehabilitation wheelchair evaluations). The assessment must address both the member’s current and expected future mobility needs.

Mobility Devices for Members with Recent Spinal Cord Injuries (SCIs) or Brain Injuries (BIs)
Authorization requests must include therapy notes detailing the member’s progress toward goals, the expected outcome of therapy for the member, and the expected time until maximum benefit from therapy is achieved.

Power Mobility Devices for Members under Age 4
Power mobility devices will not be considered for members under age 18 months.

Authorization requests for power mobility devices for children under age 4 must include the following:

1. Documentation, including any relevant assessments, that the child is developmentally and cognitively ready to begin to operate a power wheelchair
2. Documentation that the child is expected to use a powered mobility device as a primary means of mobility for several years. It is not necessary that there is no expectation or hope of functional walking in the future.
3. Documentation of the age-appropriate ADLs for which the child is expected to use the power mobility device
4. Documentation that the caregivers have carefully considered the risks and benefits of independent power mobility for very small children
5. Due to the expense of mobility devices for very small children, it is particularly important that issues of transportation be addressed to eliminate the need for multiple mobility devices

Documentation of Member Ability to Use In-Home and Transportation Trials
All authorization requests must include a trial in the home that demonstrates the mobility device fits in all necessary areas of the home and the member is able to use the mobility device in all necessary areas of the home.

1. During the trial, also address transportation of the mobility device in the member’s vehicle if appropriate. If the member does not have a vehicle, address the member’s primary transportation method.
2. For manual wheelchairs without seating or propulsion options, the trial may be performed with the same or similar equipment.
3. For other mobility devices, the trial must be performed with equipment with the same specifications as to measurement and maneuverability and power options.

In all cases, the trial must demonstrate the proposed device is medically necessary and appropriate for the member.

Mobility device authorization requests must include the physician’s order for the device. The order must be signed and dated by the physician.

An authorization request form must be completed for both the wheelchair and the accessories, if applicable. The Mobility Device Authorization Form (DHS-4315-ENG) must be completed and signed by the person recommending and fitting the mobility device. The form must indicate the credentials (doctor of medicine [MD], PT, OT, ATP) of each person signing the form.

1. Submit the mobility device base HCPCS code for an authorization number when requesting an authorization for purchase or rental beyond three months. List the recommended device by name and model number.
2. List all standard and non-standard accessories/options on separate lines on the authorization request, even if the individual item does not require authorization. List each item by HCPCS code, appropriate modifier, and quantity, with the charge and medical necessity documentation for non-standard items.
3. When multiple items that are different but require the miscellaneous code K0108 are requested, each item must be listed on a separate line of the authorization request, with modifier 76 on the second and subsequent lines. A unique description of each item must be entered into the model number field for each line. The unique description may be a model number or narrative description up to 20 characters.
4. Documentation must address the member’s medical need, and how the mobility device and each option or accessory meets that need. All options and accessories, and the specific medical justification for each option or accessory, must be listed on the request, although only the major accessories will be reviewed for medical necessity.
5. Standard items included in the initial issue of the device will not be reviewed for medical necessity but will be listed on the authorization letter as an approved item.
6. All major accessories will be listed on the authorization letter by procedure code, whether approved or denied, with the allowed dollar amount if approved.
7. All coverage determinations are based on the least costly, most effective, and medically necessary mobility device for the individual member.

Repair/Modification Authorization Requests

When requesting authorization for repairs/modifications to a mobility device not originally authorized by PrimeWest Health, include documentation of medical necessity for the device and the accessories to be repaired/replaced.

Replacement of worn batteries, battery chargers, wheels, or tires/arm pads is not considered a repair.

Authorization is not required, regardless of submitted charge, unless the part being replaced is less than one year old. Replacement of other components is considered a repair and subject to the $1,000 limit.

Authorization may be denied if:

1. The repairs/modifications are not cost effective because of the age/condition of the device
2. The frequency/extent of repairs requested indicates the member lacks the ability to safely and appropriately operate the device
3. The repairs/modifications are requested for a device that does not currently meet Minnesota Health Care Programs (MHCP) criteria for coverage

When submitting authorization requests:

1. List all accessories/options to be replaced or repaired on separate lines on the authorization request. List each item by HCPCS code, quantity, and the usual and customary (U&C) charge. Use appropriate modifier(s) as determined by DOS.
2. When multiple items that are different but require the miscellaneous code K0108 are requested, each item must be listed on a separate line of the authorization request with modifier 76 on the second and subsequent lines. A unique description of each item must be entered into the model number field for each line. The unique description may be a model number or narrative description up to 20 characters.
3. Include the estimated labor time on the authorization request with K0739, as appropriate.
4. If adding accessories to an existing wheelchair, include medical necessity documentation for each accessory.
5. Include the original mobility device prior authorization number, if available, or the approximate purchase DOS.
6. If repairs are needed because of damage to the device, specify the cause of the damage.
7. All approved items will be listed on the authorization, with the approved payment amount.

When requesting authorization for repairs/modifications to a mobility device:

1. For all parts and accessories to be repaired or replaced:

1. Use modifier RB for items being repaired
2. Use modifier NU for items being installed as a modification
3. Use modifier RA for items being installed as a replacement for the same accessory
4. U&C charge(s)

Billing

1. Submit the U&C charge for the mobility device and part/accessories. Payment will be the balance of the lesser of the billed amount or the approved amount, after any primary or secondary payers have made payment.
2. If billing for parts/accessories for two approved wheelchairs, clearly indicate this in the notes field. Include the authorization number that refers to the appropriate wheelchair in the notes field.
3. Do not bill repairs over a span of dates.
4. When a provider sends a part or accessory to a manufacturer for repair, bill using the appropriate HCPCS code for the part and RB modifier. Submit the invoice from the manufacturer as an attachment to show cost. Bill K0739 for the provider’s labor for removal/reinstallation of the part or accessory. Follow usual PrimeWest Health policies in determining if a prior authorization is necessary.
5. Bill items that require manual pricing using the 837P professional electronic claim format with the manufacturer’s invoice or price list as an attachment as described in Billing Requirements. Items included in an approved authorization do not require manual pricing.
6. If billing for parts/accessories for two medically necessary member-owned wheelchairs, clearly indicate this in the notes field, including the authorization number or serial number that refers to the appropriate in the notes field.
7. If you bill K0739, PrimeWest Health will deny additional claims billed by the same provider for the same DOS.
8. The KE modifier can be billed for wheelchair accessory codes listed in Attachment A of the Centers for Medicare & Medicaid Services (CMS) Manual System Change Request 11784 when provided in connection with mobility device codes described by HCPCS codes E1161, E1229, E1231 – E1239, K0005, K0009, and K0898.
9. The KU modifier can be billed for wheelchair accessories and seat and back cushion codes listed in Attachment A of the CMS Manual System Change Request 12345 and Attachment A of the CMS Manual System Change Request 12453 when provided in connection with Group 3 power wheelchairs, complex rehabilitative manual wheelchairs, and certain other manual wheelchairs described by HCPCS codes E1161, E1231 – E1238, K0005, K0008, and K0848 – K0864
10. Repairs to equipment owned by Medicare members: Effective April 1, 2009, Medicare established Unit of Service Allowances for repairs to some commonly repaired items. When the actual repair time exceeds Medicare’s allowance, bill the labor on two lines. Line one must follow Medicare billing rules. On line two, bill K0739 or K0740 as appropriate and use modifier GZ (item or service expected to be denied as not reasonable and necessary) and the number of units that exceed Medicare’s allowance.

Approved Purchase/Rental Billing for Devices Approved on a Single-line Authorization

Submit a claim for the approved power-operated vehicle or wheelchair base; make sure the HCPCS code, modifiers, and the description on the claim match the same information on the prior authorization.

Submit the U&C charge for the mobility device, not the approved amount, on the authorization letter. Payment will be the balance of the lesser of the billed amount or the approved amount, after any primary or secondary payers have made payment.

On a second claim, submit all options and accessories provided at the initial issue of the mobility device. For any accessories for which authorization was approved, enter the authorization number in the notes/comments field on the claim information tab, or attach documentation that lists each approved option/accessory. Do not enter the authorization number in the authorization field.

Repairs/Modifications Billing for Devices Approved on a Single-Line Authorization

Submit one claim per mobility device.

1. Bill each repaired part or accessory using the appropriate HCPCS code for that part/accessory with modifier RB.
2. Bill each part/accessory installed as a modification using the appropriate HCPCS code for that part/accessory with modifier NU.
3. Bill each part/accessory being installed as a replacement for the identical item using the appropriate HCPCS code for that part/accessory with modifier RA.
4. Bill multiple items that are different but require the miscellaneous code K0108 using the appropriate HCPCS code with appropriate modifiers on the first line item, and K0108 with modifier 76 and the appropriate modifier(s) NU/RA/RB on each additional line. Enter a description on each line specific enough to clearly identify each different item, such as manufacturer, part, or item number and brief description of the item.
5. Bill labor on the same claim, using K0739.
6. Enter the number from the approved authorization request in the “Notes” field. Do not enter the number in the “Authorization” field.

Approved Purchase/Rental/Repair Billing for Devices Approved on a Multi-Line Authorization

Submit one claim for the approved power-operated vehicle or wheelchair base (for purchase/rental) and all approved parts/accessories (for all claims); make sure the HCPCS codes, modifiers, and the description on the claim match the same information on the prior authorization.

Enter the authorization number in the authorization field in the authorization field for each line.

Use of Medicare Modifiers

Providers must follow Medicare guidelines for use of modifiers under the Medicare DMEPOS fee schedule. PrimeWest Health will apply the appropriate Medicare rate to lines billed with these modifiers.

Members with Third Party Coverage or Medicare

When PrimeWest Health is not the primary payer, other insurance must be exhausted before submitting a claim for payment to PrimeWest Health.

1. Utilization Management (UM) at PrimeWest Health must approve an authorization before PrimeWest Health can make a payment.
2. UM will make an authorization request after the fact, but authorization must be obtained. Refer to the “Authorization” subsection in the Mobility Devices section for instructions.
3. The mobility device must meet all PrimeWest Health medical necessity requirements, and documentation included in the request must identify the mobility device in detail.
4. Include the amount the primary payer will reimburse for the mobility device in the authorization request.
5. Members/providers must comply with policies/procedures of the primary insurance.

Nebulizers

Nebulizers administer vaporized medication to individuals receiving nebulized medications.

Eligible Providers

The following providers may provide nebulizers:

1. Federally qualified health centers
2. Home health agencies
3. Indian Health Services
4. Medical suppliers
5. Pharmacies
6. Rural health clinics

Third Party Liability (TPL) and Medicare

Providers must meet any provider criteria, including accreditation, for third party insurance or Medicare. This is to assist members for whom PrimeWest Health is not the primary payer.

Eligible Members

Nebulizers are covered for eligible PrimeWest Health members with a variety of respiratory or pulmonary conditions and diseases and other serious conditions requiring nebulized medications.

Covered Services

The following services (codes) are covered:

1. E0570 (with compressor)
2. E0572 (aerosol compressor, adjustable pressure, light duty for intermittent use)
3. E0574 (ultrasonic/electronic aerosol generator with small volume nebulizer)
4. E0575 (ultrasonic, large volume)
5. E0580 (durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter)
6. E0585 (with compressor and heater)

For codes E0570, E0572, E0574, and E0585, one nebulizer is allowed every five years. For code E0580, one nebulizer is allowed every three years. If more than the allowed quantity is medically necessary, providers must submit a claim with an attachment explaining the circumstances requiring replacement.

Authorization

Authorization is always required for ultrasonic, large-volume nebulizers (E0575) and such devices are authorized as capped, rental items only. Provide documentation of the medical necessity for this service and what type of treatment has been tried in the past with outcome of that past treatment.

One nebulizer is allowed every five years. If more than allowed quantity is medically necessary, providers must submit a claim with an attachment explaining the circumstances requiring replacement.

Provider must maintain required documentation in member’s file.

The need for a battery operated model and one or more of the following conditions must be documented:

1. Previous life-threatening bronchospasms
2. Aerosol drug therapy is more frequent than twice per day for a member who is away from home at school or work on a daily basis
3. Cystic fibrosis (CF)
4. Bronchiectasis

Initial dispensing includes the following:

1. Compressor
2. Mask
3. Mouthpiece
4. Reusable nebulizer
5. Tubing

Separately bill the following:

1. Disposable mouthpieces
2. Face mask
3. Replacement of disposable hand held nebulizer
4. Replacement tubing

Non-Mobility Equipment Repairs

PrimeWest Health pays for repairs to medically necessary member-owned Durable Medical Equipment (DME) and prosthetics/orthotics. PrimeWest Health pays for maintenance service agreements for some member-owned equipment that requires frequent servicing or calibration.

Third Party Liability (TPL) and Medicare

Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist members for whom PrimeWest Health is not the primary payer.

PrimeWest Health quantity limits and thresholds apply to all members unless only Medicare co-insurance or deductible is requested.

Eligible Members

Repairs to member-owned medically necessary DME and prosthetics/orthotics are covered for eligible PrimeWest Health members.

Covered Services

Codes

K0462: temporary replacement for patient-owned equipment being repaired, any type
K0739: repair or non-routine service for DME other than oxygen, labor component, per 15 minutes
K0740: repair or non-routine service of oxygen equipment, labor component, per 15 minutes

The following codes are eligible for maintenance service contracts if the equipment is recipient-owned and meets criteria: B9000, B9002, B9004, B9006, E0445, E0450, E0460, E0461, E0463, E0464, E0470, E0471, E0482, E0483, E0600, E0609, E0617, E0779, E0781, E1390, E01392, E1399, K0606, and K0730. Authorization is sometimes required.

If providers do not have appropriate loaner equipment for the member to use while equipment is being repaired, rental equipment may be provided. PrimeWest Health will reimburse providers for one month’s rental. To bill, use K0462 and include the Healthcare Common Procedure Coding System (HCPCS) code of the item being repaired in the “Comments” section of the claim.

If the rental is longer than one month, providers must submit a request for authorization. Explain the unusual circumstances and rental time needed.

Equipment should not be repaired if the cost to repair exceeds the cost to replace, or if the repair will not significantly extend the usable life of the equipment.

Maintenance service contracts are available for patient-owned equipment that is necessary to sustain life, and which requires regular, professional attention beyond the capability of most members. Examples of the types of equipment that may require a maintenance service contract are patient-owned oximeters, ventilators, respiratory assist devices, and defibrillators.

When a maintenance service contract is approved, the provider becomes responsible for all regularly scheduled service to keep equipment functioning correctly for six months. If repairs are needed, the repairs may be provided in addition to the maintenance service contract.

See the Mobility Devices section for information on repairs to wheelchairs or power operated vehicles.

Authorization

Equipment that always requires authorization for purchase always requires authorization for repair or modification.

Equipment that sometimes requires authorization for purchase and equipment that never requires authorization for purchase will require authorization for repair or modification if parts combined with labor charges total $1,000 or more.

Maintenance service agreements for E1399 always require authorization.

When requesting authorization for a maintenance service agreement for a member-owned equipment item, use the appropriate equipment procedure code with modifier MS and include the date the warranty period ended. One unit equals a six-month service agreement.

If PrimeWest Health did not authorize or purchase the equipment being repaired/maintained, include documentation that the equipment meets current medical necessity criteria.

Requests for repairs where the cost to repair exceeds 90 percent of the cost to replace must include documentation to show that the repair is a less costly alternative over time than replacement with a new item under warranty.

If the equipment is nearing the end of its expected usable life (usually five years), document how long the repair is expected to extend the lifespan of the equipment.

Billing

1. Use the 837P professional claim format.
2. If the member has Medicare, PrimeWest Health will pay the deductible/co-insurance on any units for which Medicare made payment. Any units for which Medicare denies payment must meet PrimeWest Health quantity and coverage limits.
3. Do not bill repairs over a span of dates.
4. When replacing a battery or power cord that does not require billing associated labor, providers may use either the HCPCS code for the equipment with modifier RB or A9999 with modifier NU.
5. For other repairs, use the HCPCS code for the equipment with modifier RB for materials.
6. Use K0739 or K0740 for labor associated with the repair.
7. Bill for the number of units actually performed based on the actual repair time.
8. For repairs to equipment owned by Medicare beneficiaries: Effective April 1, 2009, Medicare established Unit of Service Allowances for repairs to some commonly repaired items. When the actual repair time exceeds Medicare’s allowance, bill the labor on two lines. Line 1 must follow Medicare billing rules. On line 2, bill K0739 or K0740 as appropriate and use modifier GZ (item or service expected to be denied as not reasonable and necessary) and the number of units that exceed Medicare’s allowance.
9. Attach appropriate documentation for pricing materials/parts.

Nutritional Products and Related Supplies

A nutritional product is a commercially formulated substance that provides nourishment and affects the nutritive and metabolic processes of the body. Enteral nutritional products are a covered service for eligible PrimeWest Health members who meet criteria for medical necessity.

Parenteral nutritional products are considered drugs and only a pharmacy may dispense these solutions. See the Pharmacy section for information about parenteral nutrition.

Nasogastric tubes, gastrostomy/jejunosotomy tubes (feeding tubes), enteral supply kits, and enteral nutrition infusion pumps are supplies used to administer enteral nutritional products to individuals who are unable to take enteral nutritional products orally.

Eligible Members

Enteral nutrition is covered for eligible PrimeWest Health members who need nutritional supplementation because solid food or the nutrients in the food cannot be properly absorbed by the body; for treatment of phenylketonuria (PKU); hyperlysinemia; maple syrup urine disease (MSUD); or a combined allergy to human milk, cow’s milk, and soy formula. Enteral nutrition may be covered for members with other specific medical conditions.

Covered Services

Enteral Nutritional Products

Codes: B4149 – B4162 (For these codes, 100 calories = 1 unit), S9435

Only products classified by Medicare’s Pricing, Data Analysis, and Coding (PDAC) contractor are covered. If you are unsure of what Healthcare Common Procedure Coding System (HCPCS) code to use refer to the Durable Medical Equipment Coding System (DMECS) Product Classification List. Up to 1,050 units per month of enteral nutrition are covered for members who meet criteria.

Documentation must support the need for the number of units requested. Oral enteral nutrition for treatment of PKU, hyperlysinemia, or MSUD do not require authorization unless the member is under age one.

Authorization

Authorization is required for all orally consumed enteral nutrition after the first 30 days of dispensing, for contracted providers (out-of-network providers require authorization before providing the service).

For contracted providers, no authorization is needed if the member has one of the following:

1. PKU
2. Hyperlysinemia
3. MSUD
4. Members (over age one) receiving enteral nutritional supplements through a feeding tube (a valid tube—feeding diagnosis must be on the claim or it will be denied). Members under age one do require a Service Authorization, even if receiving enteral nutritional through a feeding tube.

The prescribing physician must complete and sign the Enteral Nutrition Service Authorization Form and provide the completed form to the pharmacy, home health agency, or medical supply provider.

The provider must submit the authorization request along with the completed Enteral Nutrition Service Authorization Form and any other documentation that indicates the medical need for oral feeding with an enteral nutrition product.

Documentation for all requests should include the following:

1. The specific enteral nutrition product requested (and the HCPCS code)
2. The average number of calories to be obtained per day from the enteral nutritional product
3. The average number of calories to be obtained per day from other sources
4. The medical condition that requires enteral nutrition product (plus the specific documentation indicated under each category of medical condition, see below)
5. A list of all the foods the member is able to consume and a list of all the foods the member has tried but cannot consume
6. The types of food preparation that have been tried (mechanically chopped, blenderized)

Categories of Medical Conditions

Nutrition for Members under Age 1

Children under age 1 may be able to get infant formula through the Women, Infants, and Children (WIC) program. Instruct families to contact their county human services or county public health office.

All enteral nutrition products for children under age 1 require authorization. Document that the specific formula that is required is not available to the child through WIC or that WIC does not provide the formula in quantities sufficient to meet the child’s medical need. The child must meet one of the medical necessity criteria below.

Nutrition for Members with Feeding Tubes

Enteral nutritional products are medically necessary for members with feeding tubes. Authorization will be approved for members under age one with documentation that WIC cannot meet the child’s medical needs. Authorization is not required for members over age 1.

Oral Nutrition for Members with Inborn Errors of Metabolism

Enteral nutritional products are medically necessary for members with many inborn errors of metabolism. Oral enteral nutritional products manufactured for the treatment of PKU, hyperlysinemia, or MSUD are covered with authorization for members under age 1 and without authorization for members over age 1 if the member has the associated diagnosis. Oral enteral nutritional products manufactured for the treatment of other inborn errors of metabolism are covered with authorization if the member has the associated diagnosis.

Solid food products specially manufactured for treatment of amino-acid transport and metabolism including PKU and MSUD are covered up to $525 per calendar month when obtained from an enrolled medical food supplier.

Oral Nutrition for Members with Allergies

Enteral nutritional products may be medically necessary for members with a combined allergy to cow’s milk, human milk, and soy milk. Oral enteral nutritional products are covered with authorization if the member has a combined allergy to cow’s milk, human milk, and soy that is supported by appropriate medical testing and documentation. It is expected that the need for oral enteral nutritional products will decrease as the member ages and additional foods are added to the diet. If the member gets less than 75 percent of daily nutrition from a nutritionally complete enteral nutrition product, there must be a detailed plan to decrease dependence on the supplement. The plan may be written by a nutritionist, an SLP, or a physician.

Oral Nutrition for Members Who Cannot Properly Absorb Solid Food or Nutrients

Enteral nutritional products are medically necessary if the member has a medical condition that causes an inability to absorb adequate nutrients, and which has led to weight loss. Oral enteral nutritional products are covered with authorization if the member meets criteria. Documentation must establish all of the following:

1. The member has a diagnosed medical condition:

1. Mechanical inability to chew or swallow solid or pureed/blenderized foods
2. Mal-absorption problem due to disease or infection
3. Oral aversion which significantly limits the ability to get adequate nutrition through solid or pureed/blenderized foods
4. Weaning from total parenteral nutrition (TPN) or feeding tube

2. The medical condition leads to inability to consume or absorb adequate nutrients
3. The member has experienced significant weight loss over the past six months or, for children under age 21, has experienced significantly less than expected weight gain
4. If the member gets less than 75 percent of daily nutrition from a nutritionally complete enteral nutrition product, there must be a detailed plan to decrease dependence on the supplement. The plan may be written by a nutritionist, an SLP, or a physician.

Oral Nutrition for Members with Non-Healing Wounds

High protein enteral nutritional products are covered for up to six months with authorization if the member has one or more wounds that have not responded to treatment for at least 30 days, and a dietary assessment has determined that the member has a nutritional deficit which may be impeding healing. Documentation must include a nutritional plan which is written by a nutritionist, physician, or other health care provider.

Supplies for Enteral/Parenteral Nutrition

Enteral Feeding Supply Kits

Codes: B4034 – B4036, B4148

Thirty-one enteral feeding supply kits per month are medically necessary for members receiving enteral nutritional products through a feeding tube. The feeding supply kit must correspond with the method of administration and must contain all supplies necessary for feeding using that method of administration for one day. For members who use the same or a different method of administration at work or school, up to 20 additional enteral feeding supply kits per month are covered. Documentation on file at the provider’s office must support the need for additional feeding supply kits. Authorization is needed if more than 51 enteral feeding supply kits are needed in a month.

Feeding Tubes

Codes: B4081 – B4088

Although most individuals who use a feeding tube only require one tube every 2 – 3 months, up to two tubes per month may be medically necessary for individuals with more than one tube site or for individuals with highly acidic gastrointestinal (GI) tracts. Low-profile feeding tubes are medically necessary for infants and children, for individuals with cognitive impairments who are at risk of dislodging a standard feeding tube, and for other individuals as determined by the physician. The provider must maintain documentation to support the quantity and type of feeding tubes supplied.

Feeding Pumps

Codes: B9000 – B9006, E0791 (Enteral/Parenteral Infusion Pumps)

A parenteral infusion pump is medically necessary for members for whom parenteral nutrition is required. An enteral infusion pump is medically necessary for members with feeding tubes for whom gravity or syringe feeding is not appropriate. Authorization is required only for maintenance service or for repairs when the cost of the parts and labor exceeds $1,000. One pump is covered per five years. Consider the member’s current and expected lifestyle when selecting a stationary versus portable pump. If a pump must be replaced due to theft or damage, providers must submit a claim with an attachment explaining the circumstances. Authorization is required for maintenance service contracts or for repairs to patient-owned pumps when the cost of the parts and labor exceeds $1,000. Refer to the Non-Mobility Equipment Repairs section for more information.

Supplies Not Otherwise Classified

Codes: B9998 – B9999 (For Enteral/Parenteral Supplies)

Up to 31 extension sets per month are medically necessary for members with low-profile feeding tubes. Up to 30, 35 ml or 60 ml syringes per month are medically necessary for individuals receiving medication through a feeding tube. One carrying case per year is covered for members with portable feeding pumps.

Food Thickeners

Code: B4100 (For this code, 1 ounce = 1 unit)

Food thickeners (Simply Thick, Thicken-It) may be medically necessary for individuals at risk of choking or aspirating liquids.

Providers must have documentation of the following in their records before providing food thickeners:

1. Swallowing study or swallowing evaluation by a speech and language pathologist with a history of aspiration
2. Plan of care and a plan for follow-up at least annually

Electrolyte-Containing Fluids

Codes: B4102 and B4103 (500 ml = 1 unit)

Electrolyte-containing fluids may be medically necessary for medical conditions related to malabsorption or malnutrition. Authorization is always required when given orally.

Authorization requests must meet the following criteria:

• The ordering physician has documented medical necessity, including applicable diagnoses and length of need. Documentation must demonstrate that the member cannot absorb adequate nutrients or requires fluids. Fluids for members only requiring electrolytes are not covered.
• The provider must discuss with the member and document in the medical record the benefits of these fluids and why other nutritional products do not satisfy the needs of the member.

In-line Cartridges Containing Digestive Enzymes

Code: B4105

Authorization is always required. Members must meet the criteria for enteral feeding and have a diagnosis of exocrine pancreatic insufficiency or fat malabsorption as shown in clinical documentation (not just a letter of medical necessity).

Pasteurized Donor Human Milk

Code: T2101 (one ounce = one unit)

Pasteurized donor human milk is covered for eligible PrimeWest Health members from birth to age 12 months who meet nutrition criteria for pediatric members. Up to 32 units per day are covered for members who meet criteria. 

Donor human milk must be obtained from a milk bank and adhere to quality guidelines consistent with the Human Milk Bank Association of North America. When receiving donor human milk, the milk bank screens and approves all donor mothers and monitors and tests all donated milk. Pasteurization removes bacteria and other harmful organisms from the donor human milk. The entire process ensures the milk is completely safe to be consumed by infants in need.

The provider must address the benefits and risks of using donor human milk such as the effects of pasteurization, immune properties, nutrients, and growth factors to the parent. The provider must also address the milk banking process, including donor screening, pasteurization, milk storage, and transport of the milk. The physician may procure this information from the donor milk bank.

Documentation must include the following:

• The ordering physician must document medical necessity, including applicable diagnoses and length of need
• The provider must discuss and document in the medical record the benefits and risks of donor human milk and other feeding alternatives with the infant’s parent or guardian

Non-Covered Services

1. Nutritional products for healthy newborns
2. Nutritional products for persons living in long-term care facilities (LTCFs) (included in the per diem)
3. Nutritional products for which the need is nutritional rather than medical or is related to an unwillingness to consume solid or pureed foods
4. Nutritional products which are requested as a convenient alternative to preparing/consuming regular foods
5. Nutritional products for which coverage is requested because of an inability to afford regular foods or supplements (refer the member to their county human services office)
6. Food thickeners for persons living in LTCFs (included in the per diem)
7. Food thickeners for infants under age 1 who were born at less than 37 weeks gestation due to Food and Drug Administration (FDA) caution
8. SimplyThick brand food thickener for infants under age 1 regardless of gestational age at birth is not covered due to FDA caution
9. Energy drinks
10. Sport shakes
11. More than one enteral supply kit per day for syringe or gravity-fed feedings

Billing

1. Use the 837P professional claim format.
2. Report the ordering provider in the “Other Provider Types” section of the claim format.

Home infusion therapy (HIT) pharmacies billing enteral nutrition supplies (B4034, B4035, B4036, B4081, B4082, B4083, B4087, B4088, B4148, B9002, E0776) not related to the HIT services should use modifier U3.

Enteral Nutrition Products When Authorization is Not Required

A valid diagnosis of PKU, hyperlysinemia, MSUD, or tube-feeding must be on the claim or the claim will deny for needing authorization.

Enteral Nutrition Products When Authorization is Required

HCPCS codes and modifiers on submitted claims must be identical to the approved authorization to prevent a denial.

All Claims for Enteral Nutritional Products

Enter the following information on all claims for enteral nutritional products:

1. Modifier BO for members taking their enteral nutrition orally
2. A valid diagnosis code to the greatest specificity indicating the medical condition that requires the product
3. The date of service (DOS) is the date the product was dispensed to the member. Do not use a date span.
4. The appropriate HCPCS code for the product dispensed
5. The appropriate number of units dispensed (1 unit = 100 calories)
6. The product name in the comments/description field when product-specific pricing is requested

Pricing for Enteral Nutritional Products

1. B4088 with modifier U3, billing for a kit, requires by-report or product-specific pricing
2. B4149 – B4155 with modifier NU, with or without modifier BO: Medicare fee schedule rate, by report or product-specific pricing
3. B4153 – B4155 with modifiers NU and U3, with or without modifier BO: product-specific pricing
4. B4157 – B4162 with modifier NU, with or without modifier BO: product-specific pricing

Include pricing documentation with claims for products that are listed as “*By-Report” on the Enteral Nutrition Price List B4149 – B4155 and B4157 – B4162.

New pricing documentation must include the following:

1. Product code (the UPC or NDC)
2. Package size (amount per case or individual)
3. Total calories per can or packet
4. Invoice pricing information

Gastrostomy/Jejunosotomy Tubes and Supplies Not Otherwise Classified

1. Bill B4087 – B4088 only for the feeding tubes. Use B9998 for all related supplies including extension sets.
2. Include a valid diagnosis code to the greatest specificity indicating the medical condition that requires the tube feeding.
3. The DOS is the date the item was dispensed to the member. Do not use a date span.
4. Enter the item name in the comments/description field.
5. Do not use B9998 for feeding supply kits or for syringes smaller than 35 ml.

Enteral Feeding Kits

1. Use the HCPCS code that is appropriate to the ordered method of feeding.
2. The DOS is the date the item was dispensed to the member. Do not use a date span.

Orthopedic and Therapeutic Footwear

Therapeutic footwear is used to prevent diabetic ulcers. Orthopedic footwear is used by individuals with structural conditions of the foot.

Therapeutic shoes, modifications, and inserts must be prescribed by a podiatrist or physician knowledgeable in the fitting of diabetic shoes and inserts.

Orthopedic shoes, modifications, and inserts must be prescribed by a podiatrist or physician knowledgeable in the fitting of orthopedic shoes and inserts.

All shoes, modifications, and inserts must be fitted and furnished by a qualified individual such as a podiatrist, pedorthist, orthotist, or prosthetist.

Orthotics are covered for all eligible PrimeWest Health members.

Definition

Affiliate: A person who directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, the ordering physician or consultant.

Covered Services

Therapeutic Shoes, Modifications, and Inserts for People with Diabetes

Codes

A5500 – A5501: therapeutic shoes
A5503 – A5507: modifications to therapeutic shoes
A5510 – A5513*: inserts for therapeutic shoes
K0903*: inserts for therapeutic shoes

*The following limits apply:

• A5510: limit of 4 units per calendar year
• A5512, A5513, K0903: limit of 6 units per calendar year

Custom-made or stock therapeutic shoes and modifications to therapeutic shoes are covered for PrimeWest Health members with diagnosed diabetes and one or more of the following conditions:

1. Previous amputation of the other foot, or part of either foot
2. History of foot ulceration of either foot
3. History of pre-ulcerative calluses of either foot
4. Peripheral neuropathy of either foot
5. Foot deformity of either foot
6. Poor circulation of either foot

Inserts for therapeutic shoes, whether custom-made or stock, are covered only when the member has covered therapeutic shoes.

Two pairs of therapeutic shoes and modifications are covered without authorization in a calendar year. They can be dispensed at the same time or at different times. The limits for inserts are listed previously.

For members in the Prime Health Complete and PrimeWest Senior Health Complete programs, Medicare covers one pair of therapeutic shoes and three pairs of inserts in a calendar year. The second pair of therapeutic shoes, if needed, will be covered under the Medicaid benefit.

Service Authorization is required for therapeutic shoes or inserts beyond the threshold.

PrimeWest Health uses the coding guidelines for therapeutic shoes, modifications, and inserts that are found in the Medicare Local Coverage Article for Therapeutic Shoes for Persons with Diabetes for Medicare’s Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC) for the state of Minnesota.

Orthopedic Shoes and Inserts

Authorization is always required for orthopedic shoes. Provide documentation as indicated below.

If the orthopedic shoe is approved, the inserts do not need authorization for up to three pairs per year. If more than three pairs of inserts are needed in a year, authorization is required.

Codes

L3000 – L3031: custom inserts
L3040 – L3060: premolded, removable arch supports
L3070 – L3100: non-removable arch supports
L3140 – L3150: abduction and rotation bars
L3224 – L3253: orthopedic footwear
L3300 – L3595: additions and modifications to orthopedic shoes
L3600 – L3640: transfer of orthotic
L3649: orthopedic shoe, modification, or transfer NOS

PrimeWest Health will cover custom-made orthopedic shoes, modifications, and inserts when the shoe is an integral part of a leg brace, or for members with one or more of the following medical conditions:

1. Foot deformity accompanied by pain
2. Plantar fasciitis
3. Calcaneal bursitis (acute or chronic)
4. Calcaneal spurs
5. Inflammatory conditions such as submetatarsal bursitis, synovial cyst, or plantar fascial fibromatosis
6. Medial osteoarthritis of the knee
7. Musculoskeletal/arthropathic deformities
8. Neurologically impaired feet
9. Vascular conditions
10. Hallux valgus deformities in children

PrimeWest Health will cover stock orthopedic shoes for members only if the shoes are an integral part of a covered leg brace and if they are medically necessary for the proper functioning of the leg brace.

PrimeWest Health will cover stock inserts only for use in covered orthopedic shoes. Three pair of inserts and modifications are covered without authorization in a calendar year. Authorization is required only when a fourth or subsequent pair of inserts is required in a calendar year. Authorization will be granted when the items are needed because of a change in the member’s medical condition or size which requires replacement.

Foot Pressure Offloading Device (A9283)

Covered for pressure reduction of existing pressure ulcers on the foot with the appropriate diagnosis. No authorization is needed for a foot pressure offloading device if the provider is contracted.

Non-Covered Footwear

1. Stock orthopedic shoes, except when attached to a leg brace.
2. Repair costs for a prosthetic or orthotic device purchased by PrimeWest Health that is covered under warranty, or repair costs for any rented orthotic or prosthetic equipment.
3. A prosthetic or orthotic device for which Medicare has denied the claim as not medically necessary.
4. A device whose primary purpose is to serve as a convenience to a person caring for the member.
5. A device that serves to address social, recreational, and environmental factors and does not directly address the member’s physical or mental health.
6. Deluxe features of therapeutic or orthopedic shoes.
7. A device that is supplied to the member by the physician who prescribed the device, or by the consultant to the physician.
8. A device that is supplied to the member by an affiliate of the physician who prescribed the devices, or of the consultant to the physician.

Orthotics

Overview

Orthotics are used to restrict movement or support weak body parts.

Definitions

Affiliate: A person who directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, the ordering physician or consultant.

Certain Customized Items: Items that require custom fabrication are unsuitable for grouping together for profiling purposes. Therefore, there are neither customary and prevailing charges nor fee schedules established. Contractors make payment for customized items without appropriate Healthcare Common Procedure Coding System (HCPCS) codes in a lump-sum based upon individual consideration for each item. For Part A providers, this is a final payment and is not reflected as a Medicare cost in provider cost reports.

Custom-made/custom-fabricated: Made for a specific patient from his/her individual measurements and/or pattern, starting with basic materials such as plastic, metal, or leather.

Orthotic: A rigid or semi-rigid device that is used for the purpose of supporting a weak or deformed body member or for restricting or eliminating motion in a diseased or injured part of the body. Elastic support garments do not meet the definition of an orthotic because they are not rigid or semi-rigid devices. Devices that are not rigid or semi-rigid should be coded as A4466.

Physiatrist: A physician who specializes in physical medicine or who possesses specialized knowledge of rehabilitation and who is certified by the American Board of Physical Medicine and Rehabilitation (ABPMR).

Stock/off-the-shelf/prefabricated: Orthotic items that are not fabricated to an individual’s specifications. They may be adjusted or altered to meet the member’s needs, but are not made specifically for the member. An orthotic that is assembled solely from prefabricated components is considered prefabricated.

Eligible Providers

1. Medical suppliers
2. Indian Health Service (IHS)
3. Federally Qualified Health Centers (FQHCs)
4. Rural Health Clinics (RHCs)

An orthotic must be prescribed by an enrolled MHCP provider that meets at least one of the following criteria:

• A physician, physician assistant, or advance practice registered nurse who is knowledgeable in orthopedics, physiatry, or vascular surgery
• A physician, physician assistant, or advance practice registered nurse in consultation with an orthopedist, physiatrist, or physical therapist
• A podiatrist within the scope of their professional practice

Third Party Liability (TPL) and Medicare

Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist members for whom PrimeWest Health is not the primary payer.

PrimeWest Health quantity limits and thresholds apply to all members unless only Medicare co-insurance or deductible is requested.

Eligible Members

Orthotic devices are covered for all eligible members.

Covered Services

PrimeWest Health has adopted the Medically Unlikely Edits (MUE) published by the Centers for Medicare & Medicaid Services (CMS). If CMS has not published an MUE, PrimeWest Health has established quantity limits. PrimeWest Health will not pay claims for more units per line than are allowed by the MUE. When dispensing bilateral orthotics where more units are required than are allowed by the MUE or limit, the units must be billed on different lines, using modifiers NU RT and NU LT as appropriate.

Orthotics for the spine and lumbar-sacral orthosis (LSO)

Codes: L0112 – L1499, L0648, and L0650

An orthotic for the spine is considered medically necessary:

1. To facilitate healing of the spine or related soft tissues
2. To reduce pain by restricting mobility
3. To support weak spinal muscles or a deformed spine
4. To treat scoliosis

Orthotics for the hip

Codes: L1600 – L1755, L2040 – L2090

An orthotic for the hip is considered medically necessary:

1. To stabilize the hip
2. To correct and maintain hip abduction

One orthotic for the hip is covered per calendar year without authorization when medically necessary with the exception that authorization is required for the second or subsequent orthotic for the hip in any calendar year.

Lower limb orthotics

Codes: L1810 – L2038, L2106 – L2999, L4350 – L4631, L5856, L5857, L5858, L5973, L5980, L5987

A lower limb orthotic is considered medically necessary:

1. For treatment of contractures
2. To immobilize a limb to promote healing
3. To provide support and stability during ambulation

Four lower limb orthotics (two sets of bilateral orthotics) are covered per calendar year when medically necessary. Authorization is required for the third or subsequent set of lower limb orthotics in any calendar year.

Custom-fabricated swing-phase release and microprocessor-controlled KAFOs

Codes: L2005, L2006

Custom-fabricated knee-ankle-foot orthoses (KAFOs) with automatic lock and swing-phase release (L2005) and microprocessor-controlled KAFOs (L2006) are covered with authorization if all of the following criteria are met:

• The member is ambulatory and use of a KAFO is appropriate; and
• The member has cardiovascular, cognitive, and physical ability to use the device; and
• Documentation articulates reasonable likelihood of improved mobility or stability with the device instead of a standard KAFO; and
• Documentation articulates need for ambulation and how device enhances member’s ability to perform activities of daily living (ADLs); and
• Consideration of less costly alternatives; and
• A trial demonstrates the member is able to use the device.

Documentation must identify the ADLs for which the robotic arm is requested and the member’s performance during the trial period. Providers must give special consideration to eating as an ADL, including the member’s ability to operate the joystick and grasp and use utensils. Providers must use HCPCS code K0108 for robotic arm accessories that do not have a more appropriate HCPCS code.

Upper extremity orthotics

Codes: L3650 – L3999, L8701, L8702

An upper extremity orthotic is considered medically necessary:

1. To immobilize an extremity to promote healing
2. For treatment of contractures
3. To provide support and stability during activities of daily living (ADL)

Four upper extremity orthotics (two sets of bilateral orthotics) are covered per calendar year when medically necessary.

Authorization is required for the third or subsequent set of upper extremity orthotics in any calendar year and for subsequent new custom orthotics if the current orthotic is less than three years old for members age 21 or over or if the current orthotic is less than one year old for members under age 21.

Types of orthotics for the upper limb include shoulder orthotics (SOs), elbow orthotics (EOs), finger orthotics (FOs), elbow-wrist-hand orthotics (EWOs), wrist-hand-finger orthotics (WHFOs), wrist-hand orthotics (WHOs), shoulder-elbow-wrist-hand-finger orthotics (SEWHFOs), accessories, and additions. Documentation must include physician order and medical necessity for each type of orthotic dispensed.

Custom-fabricated powered upper-extremity assist devices (L8701, L8702)

Custom-fabricated powered upper-extremity range-of-motion assist devices are covered with authorization if all of the following criteria are met:

• Member use of an upper limb orthotic is appropriate; and
• The member has a diagnosis of one of the following:
• Amyotrophic lateral sclerosis (ALS); or
• Brachial plexus injury; or
• Brain or spinal cord injury; or
• Cerebral palsy; or
• Long-term muscle weakness; or
• Multiple sclerosis; or
• Partial paralysis; or
• Neuromuscular or neurological disease or injury; or
• Other medical condition that severely limits mobility and range of motion in upper extremities; and
• The member has the cardiovascular, cognitive, and physical ability to use the device; and
• The member does not have a comorbidity that may impede with functioning of the device; and
• Documentation articulates reasonable likelihood of improved mobility with the device instead of a standard upper limb orthotic; and
• Documentation articulates need for mobility and how the device enhances the member’s ability to perform ADLs; and
• The muscle to which the electrode is attached generates sufficient microvoltage to operate the device; and
• Consideration of less costly alternatives; and
• A trial demonstrates the member is able to use the device.

Powered upper extremity assist devices are contraindicated for the following:

• During recovery from acute injury; and
• Environments that limit safe use of the device, including flammable areas; and
• Excess pain in arm, hand, or shoulder during facilitated range of motion; and
• Insufficient myoelectric signal output for full operational use of the device; and
• Medical conditions that limit safe use of the device; and
• Physical measurements that do not meet specifications of the manufacturer; and
• Rigid spasticity in the impacted muscle groups; and
• Severe shoulder subluxation; and
• Upper extremity contracture that prevents functional movement to benefit from the device. 

Repairs to orthotic devices

Codes: L4000 – L4210

Repairs to orthotic devices are covered without authorization with the exception that authorization is required for repair/modification to an orthotic if the cost of the parts and labor exceeds $1,000.

Cranial remolding orthotics

Code: S1040

A cranial remolding orthotic is considered medically necessary for treatment of head deformities associated with:

1. Premature birth
2. Restrictive intrauterine positioning
3. Torticollis
4. “Back to Sleep” sleeping positions

Up to two cranial remolding orthotics are covered without authorization for members under age 2. Authorization is required for the third and subsequent cranial remolding orthotic.

Cranial prostheses

Code: A9282

A cranial prosthesis is considered medically necessary for treatment of medical conditions that result in hair loss.

One medical wig is covered per calendar year.

Supplies for Orthoses

Codes: L0970 – L0984, L2180 – L2861

PrimeWest Health covers supplies for orthotic devices. Supplies are covered if they are medically necessary and are required for the functioning of the orthotic device. Providers must document medical necessity and that the supply or replacement item is required for device functioning. The following list of supplies does not include all supplies covered by PrimeWest Health. The reasonable useful lifetime (RUL) for durable medical equipment (DME) applies to orthotic supplies. Refer to the Medical Supply Coverage Guide for information on quantity limits by HCPCS code. 

• Corsets for spinal orthotics are used to adjust tension and close the device. Some corsets use corset fronts (L0970, L0972), which attach to the back of the device. Full corsets (L0974, L0976) have a fabric body and closure, usually on the front of the device.
• Auxiliary crutch extensions (L0978) use a pad under the armpit to hold most of the member’s weight over the double uprights. Peroneal straps (L0980) are used with devices that tend to migrate upward as the member engages in ADLs. The straps connect to the bottom of the spinal orthotic to ensure the device does not move upward. Stocking supporter grips (L0982) attach to the top of stockings and the bottom of support garments to hold stockings in place.
• Protective body socks (L0984) are prefabricated garments composed of soft fabric and used under spinal orthotics. PrimeWest Health covers two units per member-owned orthotic device per year when the original item no longer functions. Authorization is required for excess quantities.
• Joints for limited ankle motion (L2200) are an addition to AFOs that limit ankle motion. This may involve molding a block to the device interface or otherwise manipulating the device to limit movement.
• Dorsiflexion assist (L2210) and dorsiflexion and plantar flexion assist (L2220) involve the application of a spring-loaded cylinder on the orthotic device’s ankle portion that works against a piston rod on the foot portion. The spring tension assists or resists flexion of the foot. Some items, including caliper plates (L2240), stirrup plates (L2230), and stirrups (L2260, L2265), may be attached to an existing device.
• Rocker bottoms for total contact custom-fabricated AFOs (L2232) involve customization of an existing device by adding a specialized sole structure. These items promote a more natural gait by distributing pressure more evenly in the lower extremity.
• Varus or valgus correction, including straps (L2270) and plastic modification (L2275), involves treatment of joint inversion or eversion by an AFO with a bar and t-strap on either the lateral or medial side of the device. Molded inner boots (L2280) are rigid protective coverings for the member’s ankle and foot. They usually are vacuum formed with a plaster mold of the member’s ankle and foot and composed of polypropylene or similar material.
• Abduction bars (L2300, L2310) are used to maintain abduction during healing. Molded (L2330) and non-molded (L2320) lacers are cuff-like supports that fit around the member’s calf area. They are used to address functional or structural impairments in the lower extremity. Anterior swing bands (L2335) are additions for use of attachment to devices. Pretibial shells (L2340) are additions that are molded and support the member’s shin area. Extended steel shanks (L2360) are used for insertion between shoe soles to ensure more rigidity to the shoe. Patten bottoms (L2370) are attachments to KAFOs that transfer weight to the member’s device and upper leg.
• Torsion control, including ankle joint and half solid stirrups (L2375) and straight knee joints (L2380), involves treatment of knee instability. These items stabilize the knee joint by managing rotational forces of the knee. Heavy-duty straight knee joints (L2385) are 180-degree stop unicentric joints for use with KOs and KAFOs. Polycentric knee joints (L2387) ensure stability at full extension and easy movement during swing phase for custom KAFOs. Offset knee joints (L2390, L2395) are additions that enhance knee stability.
• Suspension sleeves (L2397) are sometimes used with lower limb orthotic devices to secure the device in place and enhance mobility and device effectiveness. These devices feature a liner that makes a nonslip suction-type contact to the member’s skin.
• Knee joint additions are used for treatment of knee instability. Drop locks (L2405) involve the member lifting a locking mechanism to drop the device from the fixed walking position. Lift loops (L2492) are gripping devices that the member uses to raise the locking ring of the drop lock mechanism. Some additions have more advanced properties, including integrated release mechanism (L2415), disc or dial lock for adjustable knee flexion (L2425), and ratchet lock for active and progressive knee extension (L2430).
• Weight bearing additions (L2500 to L2550) are used for distributing weight evenly to enhance comfort and fit. Pelvic control hip joints (L2570 to L2628) are used for treatment of hip instability. These joints are specialized to aid in pelvic control. Bands and belts (L2630, L2640) are secured to the device by hip joints. Gluteal pads (L2650) are pads that provide support to the gluteal area.
• Thoracic bands (L2660) are for use with bilateral HKAFOs. Bands, including those with paraspinal uprights (L2670) and lateral uprights (L2680), provide control of the torso and spinal alignment.
• Fracture socks, including tibial (L2840) and femoral (L2850) length, are highly elastic and may be applied to certain types of closed fractures of the lower extremity. Socks are usually used concurrently with a rigid orthotic device.
• Concentric adjustable torsion style mechanisms (L2861) for custom devices are components that incorporate power assist. The add-on component is attached to the ankle or knee component of a custom device and adds the ability to assist or resist as medically necessary.

Reasonable Useful Lifetime

The usual reasonable useful lifetime (RUL) of five years for durable medical equipment (DME) does not apply to prosthetics, including artificial limbs or eyes, or custom orthotics. Custom orthotics include devices that are custom fabricated, or custom fitted to a specific member based on their unique physical condition. PrimeWest Health covers medically necessary repairs and replacements for parts and devices. Members cannot automatically obtain a new device if the original is still in working order.

PrimeWest Health pays for the initial prosthetic devices for everyday use and bathing without authorization, unless the individual HCPCS codes always require authorization. Authorization is required for recreational prosthetics and subsequent new or replacement prosthetics for any purpose. PrimeWest Health pays for custom orthotic devices for everyday use and bathing without authorization, unless the individual HCPCS codes always require authorization. Authorization is required for recreational orthotics and subsequent new or replacement orthotic devices when the device is less than three years old.

Non-Covered Services

1. A prosthetic or orthotic device for which Medicare has denied the claim as not medically necessary
2. A device whose primary purpose is to serve as a convenience to a person caring for the member
3. A device that serves to address social and environmental factors and that does not directly address the member’s physical or mental health
4. A device that is supplied to the member by the physician who prescribed the device or by a provider who is an affiliate of the physician who prescribed the device
5. Repair costs for a prosthetic or orthotic device that is under warranty
6. Repair costs for any rented equipment
7. Orthotics when used to prevent injury in a previously uninjured limb
8. Orthotics that are to be used only during sports or other leisure activities
9. A custom fabricated orthotic when the member’s needs can be met with a prefabricated orthotic
10. Stance control orthotics (L2005)
11. Externally powered upper extremity orthotics (L3904)
12. Electronic/microprocessor-controlled orthotics, including the Sensor Walk, E-MAG

Authorization

Authorization is required when the cumulative costs in a claim are $3,000 or greater for contracted providers (out-of-network providers require authorization before providing the service, regardless of cost). Request the authorization for the base item only, but document all add-on items to allow the reviewer to have an overall picture of the item.

Authorization is required for quantities over the annual limit for hip, lower limb, upper extremity, and cranial orthotics.

Authorization is required for repair/modification to an orthotic if the cost of the parts and labor exceeds $1,000.

1. If requesting authorization for quantities over the annual limit, document why the additional orthotic is required and how the requested orthotic meets the member’s medical and functional needs.
2. If requesting authorization for repairs, document that the repair can reasonably be expected to delay replacement by at least one year.
3. PrimeWest Health will not authorize more units per line than are allowed by Medicare’s MUE. When requesting authorization for bilateral orthotics where more units are required than are allowed by the MUE, the units must be requested on different lines, with modifiers NU RT and NU LT as appropriate. Documentation must clearly establish that the greater number of units is required.
4. When multiple items that are different but require the same miscellaneous code are requested, each item must be listed on a separate line of the authorization request. A unique description of each item must be entered for each line. The unique description may be a model number or a narrative description.
5. Each line will be approved or denied.

Billing

1. If the member has Medicare, PrimeWest Health will pay only the deductible/co-insurance on any item for which Medicare made payment, regardless of any PrimeWest Health authorization.
2. Shipping/delivery/set-up costs are included in the PrimeWest Health maximum allowable payment and may not be separately billed to PrimeWest Health or the member.
3. PrimeWest Health will not pay claims for more units per line than are allowed by Medicare’s MUE. When billing for bilateral prosthetics where more units are required than are allowed by the MUE, the units must be billed on different lines, with modifiers NU RT and NU LT as appropriate.
4. Use modifier RA on the HCPCS code of the item being replaced.
5. Use modifier RB on the HCPCS code of the item being repaired. When billing labor for repairs, specify the number of units and the rate. Do not bill for setup and delivery, or for service calls that do not involve actual labor time for repairs.
6. When billing for items approved on an authorization, submit one claim for all approved lines. Make sure the HCPCS codes, modifiers, and descriptions on the claim match the same information on the authorization.
7. Enter the authorization number in the authorization field for each claim line.
8. Submit the usual and customary (U&C) charge for each line, not the approved amount from the authorization letter.
9. Use modifiers K1, K2, K3, or K4 as appropriate for lower limb prosthetics.
10. Use modifier U1 on all L HCPCS codes for devices for bathing or showering purposes.
11. Use modifier U2 on all L HCPCS codes for devices for recreational purposes.

Oximeters

Overview

Oximeters are used to measure a member’s blood oxygen saturation levels.

Third Party Liability (TPL) and Medicare

Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist members for whom PrimeWest Health is not the primary payer.

PrimeWest Health quantity limits and thresholds apply to all members unless only Medicare co-insurance or deductible is requested.

Eligible Members

All PrimeWest Health members who meet the coverage criteria are eligible.

Covered Services

Codes: A4606, E0445

Purchase or monthly rental of oximeters that are suitable for intermittent use or spot checks may be medically necessary for the following:

1. Periodically checking the oxygen saturation levels in members using long-term oxygen
2. Checking oxygen saturation levels of the member during or following a seizure

Fingertip pulse oximeters are purchase only and are covered with medical necessity. Use code E1399 and see additional billing instructions in the Billing section.

Short-term, 24-hour, or overnight continuous oximetry may be medically necessary for the following:

1. To evaluate nocturnal desaturation in patients with chronic respiratory disease
2. To determine the appropriate oxygen needs of the member, particularly when there has been a change in the member’s medical condition
3. To evaluate the need for a sleep study

Monthly rental of an oximeter that is suitable for continuous use may be medically necessary for the following:

1. Members being weaned from home oxygen
2. Infants less than 12 months of age using home oxygen
3. Members with a temporary medical need to maintain oxygen saturation within a very narrow range

Purchase or monthly rental of an oximeter that is suitable for continuous use may be medically necessary for the following:

1. Members who require mechanical ventilation
2. Members with a tracheostomy
3. Members with a long-term medical need to maintain oxygen saturation within a very narrow range
4. Members with long-term medical needs to monitor cardiac activity and oxygen saturation

Replacement oxygen probes are covered for members using oximeters.

1. Durable probes are expected to last six months.
2. Up to 10 disposable probes are covered every 30 days.
3. Disposable probes may be appropriate for members whose age or disability prevents them from safely using durable probes.
4. Durable probes should be used by members who use spot check or intermittent oximetry.

Non-Covered Services

1. Oximeters are not the community standard of care for monitoring members with asthma.
2. Oximeters are not demonstrated to be effective for diagnosis of members with suspected obstructive sleep apnea.
3. Back-up or portable oximeters are a duplication of equipment when the member has an oximeter. Providers should dispense equipment that can meet the member’s needs at home and in the community.

Authorization

Authorization is required for repairs or maintenance service to member-owned oximeters when parts and labor is more than $1,000. Authorization is required for rental beyond three months of oximeters and for all purchases of oximeters. Authorization is required for quantities of oximeter probes that exceed limits.

Authorization requests for rental or purchase of oximeters must include the following:

1. The member’s diagnosis and pertinent medical history
2. Written plan of care that includes a step-by-step protocol to be used in case of desaturation
3. Other equipment, such as apnea monitor, oxygen, or ventilator, that is used by the member and how the various equipment works together in the plan of care
4. Expected duration of need
5. Documentation of the specific oximeter model requested and its suitability to meet the member’s medical needs
6. If an oximeter suitable for continuous use is requested, clearly document why a less costly oximeter will not meet the member’s needs.

Authorization requests for additional quantities of oxygen probes must include the following:

1. The member’s diagnosis and pertinent medical history
2. Frequency of monitoring
3. Expected duration of need
4. If a durable probe is requested because replacement is required less than six months after dispensing, document the reason replacement is required.
5. A Service Authorization is required if more than five disposable probes are needed in a 30-day period. Documentation of why a durable probe does not meet the member’s needs is also required.

Billing

1. When billing for overnight oximetry, use modifiers RR and U4. Up to two units per month may be billed.
2. When billing for rental or authorized purchase of an oximeter that is suitable for intermittent use, use modifier NU or RR as appropriate, and modifier U7.
3. When billing for rental or authorized purchase of an oximeter that is suitable for continuous use, use modifiers NU or RR as appropriate.
4. When billing for fingertip pulse oximeters, use HCPCS code E1399, modifiers NU and U8. When billing for members covered by Medicare, include an attachment that clearly states “fingertip pulse oximeter not covered by Medicare” or add this statement under "claim information" in the claim’s note field in MN–ITS.
5. Oxygen probe(s) suitable for one month use is included with the original dispensing of all oximeters.
6. When billing for a durable oxygen probe, use modifiers NU and U3.

Oxygen and Oxygen Equipment

Home oxygen therapy is used to treat and prevent symptoms and complications of hypoxemia and for treatment of certain other medical conditions.

Codes: E0424, E0431, E0434, E0439, E0441 – E0444, E1390, E1392, S8120 – S8121 (Oxygen equipment and contents), E1399 with modifier QH (oxygen conserving device)

Portable oxygen concentrators are covered for rental only for PrimeWest Health members. Authorization is not required for oxygen equipment or for oxygen contents provided by contracted providers.

Required documentation must be maintained in the member’s file at the medical supplier’s office. Documentation of the following shows medical necessity:

1. When the member’s blood oxygen levels indicate the need for oxygen therapy and one of the following is present:
   1. Diagnosis of severe lung disease such as chronic obstructive pulmonary disease (COPD), diffuse interstitial lung disease, cystic fibrosis (CF), bronchiectasis, etc.
   2. Diagnosis of hypoxia-related symptoms caused by an underlying medical condition such as pulmonary hypertension, congestive heart failure (CHF), erythrocytosis, etc.
   3. Short-term need due to diagnosis of conditions that usually resolve with limited oxygen therapy such as pneumonia, croup, bronchitis, etc.
2. The member has a diagnosis not directly related to hypoxia for which short-term or intermittent use of oxygen has been shown to be beneficial:
   1. Cluster headaches when other treatment has failed and the member has expressed a willingness to keep portable oxygen accessible throughout the day. If the member is not willing to keep portable oxygen accessible while away from home, oxygen is not an appropriate treatment.
   2. Pediatric bronchopulmonary dysplasia where the need for oxygen is variable and cannot be clearly established with blood oxygen levels
   3. Hemoglobinopathies in patients with a history of vaso-occlusive crisis
3. The member’s blood oxygen levels, as evidenced by blood gas or oximetry, indicates the need for oxygen therapy; and
4. Alternative treatment measures have been tried or considered and deemed clinically ineffective.

PrimeWest Health does not require specific PaO2 or oxygen saturation values for coverage. The physician’s order must clearly state the recipient’s diagnosis, the PaO2 or oxygen saturation levels, the ordered flow rate, and number of hours per day that oxygen is required.

Oxygen Services Covered under Medicaid

Providers should refer to their provider agreement with PrimeWest Health for reimbursement terms when billing for oxygen services covered under the Medicaid benefit.

Oxygen Services Covered by Medicare

PrimeWest Health follows Medicare guidelines for the coverage of oxygen rental. Payment for monthly rental of oxygen equipment during a period of continuous use will be made for up to 36 months. The oxygen rental payment includes reimbursement for the equipment, oxygen contents, maintenance, supplies and accessories, and other services necessary for furnishing oxygen and oxygen equipment. After 36 monthly rental payments have been made for the oxygen equipment, monthly payments will cease. The supplier that furnishes the oxygen during the 36-month payment period must continue to furnish the oxygen equipment during any period of medical need for the remainder of the reasonable and useful lifetime of the equipment, which is normally five years. After the five-year reasonable useful lifetime of the equipment has been reached, if the member still needs the equipment (i.e., the member meets the medical necessity for the oxygen), a new capped rental period may begin.

After the 36-month rental payment period, the supplier can bill for and receive a monthly payment for furnishing oxygen contents. Please refer to National Government Services website for a listing of those codes that are billable after the 36-month rental period.

Medicare payment for oxygen equipment is limited to 36 months. Providers may not bill PrimeWest Health for oxygen equipment supplied to Medicare beneficiaries when the 36-month cap is reached. PrimeWest Health quantity limits and thresholds only apply to dual eligible members. Providers may not transfer dual eligible members to the contract provider when the 36-month cap is reached. Providers must follow Medicare policy when serving dual eligible recipients.

To ensure reimbursement on your oxygen rental claims submitted to PrimeWest Health, we encourage you to follow the standards for claim submission. Please ensure that you are using the correct place of service (POS) code on your claims. The POS on oxygen rental claims should be the location where the member is residing at the time he/she is receiving oxygen. If the member is residing in his/her home, the POS should reflect this. If he/she is residing in a Skilled Nursing Facility (SNF), use the appropriate code to indicate the type of SNF. A complete listing of POS codes can be found on the Centers for Medicare & Medicaid Services (CMS) website.

Portable Concentrators, Home Liquefier Systems, and Home Compressor Systems

1. For portable concentrators, home liquefier systems, and home compressor systems, the provider must determine if the system is sufficient to meet all of the member’s needs, and whether the member or member’s caregivers are able to use the system safely and effectively.
2. Portable concentrators may be appropriate for members traveling for out-of-state medical care.
3. A second concentrator may be dispensed if necessary to meet the member’s needs due to high oxygen flow, or when it is necessary to have one concentrator at home and a second at school or a work place. The concentrators must be delivered on different days. Contractors must pick up concentrators for use at school during school breaks over four weeks. PrimeWest Health will cover portable gas or portable liquid oxygen systems for members with stationary concentrators.
4. All members with covered concentrators must have gaseous oxygen supplies sufficient for 12 hours emergency use.

Non-Covered Services

1. Oxygen purchased from airlines for use during travel.
2. Stands, racks, and wheeled carts for oxygen equipment are not separately covered
3. Replacement accessories for portable concentrators are not covered because PrimeWest Health does not purchase portable concentrators
4. Portable liquid or gas oxygen systems for members with portable concentrators, home liquefier systems, or home compressor systems
5. Second concentrators for use at school or work for members with portable concentrators, home liquefier systems, or home compressor systems

Billing

1. Use the 837P professional electronic claim format.
2. Appropriate codes should be used to reflect the oxygen service that was provided. If the code billed indicates contents are included in the rental, codes for additional contents will not be allowed.
3. Medicare has codes for oxygen contents that should be billed if the service is covered by Medicare.
4. When PrimeWest Health is not the primary payer, bill PrimeWest Health the same way the primary payer is billed.
5. Do not bill disposable accessories or oxygen for emergency backup separately. The cost of disposable accessories is included in the contracted rates for gaseous and liquid oxygen systems. This applies to both contract and non-contract vendors.

Medicare does not cover the rental or purchase of oxygen equipment or contents when the member is living in a long-term care facility under a residential stay. Providers must follow MHCP billing procedures, including instructions regarding S8120 and S8121 for excess quantities of contents. It is not necessary to bill Medicare before billing PrimeWest Health

Patient Lifts and Seat Lift Mechanisms

A seat lift mechanism is used to allow a person to move from a seated position to a standing position. A patient lift is used to transfer the person from one surface to another.

Eligible Members

Patient lifts and seat lift mechanisms are covered for all eligible PrimeWest Health members who meet coverage criteria. PrimeWest Health follows InterQual^® and/or Minnesota Department of Human Services (DHS) criteria for medical necessity determinations. Members in nursing facilities and Intermediate Care Facilities for the Developmentally Disabled (ICF/DDs) are not eligible for patient lifts or seat lift mechanisms.

Covered Services

Codes

E0621: Sling or seat, patient lift, canvas or nylon
E0630, E0635, E0636, E0639: Patient lifts
E0627 – E0629: Seat lift mechanisms

Hydraulic/mechanical patient lifts described by E0630 require Service Authorization. Provide documentation of the following:

1. The member requires the assistance of two people to transfer between a wheelchair, bed, commode, or other surfaces in the home. The member is bedridden without the lift.
2. The member cannot be safely transferred without a lift due to the member’s medical condition or caregiver limitations. The caregiver is capable of operating the lift.
3. The lift is documented as fitting in all necessary parts of the member’s home.

Multi-positional patient support systems with integrated lift described by E0636, and moveable patient lifts described by E0639 are covered for members whose unique medical needs cannot be met with a less costly lift. Both require Service Authorization.

Electric patient lifts described by E0635 require Service Authorization. Provide documentation as indicated for hydraulic/mechanical patient lifts, plus the following:

1. The member has a medical condition that prevents safe transfer using a hydraulic/mechanical lift
2. The primary caretaker is unable to operate a hydraulic/mechanical lift but can operate an electric lift and can perform all necessary cares

Seat lift mechanisms require Service Authorization. Provide documentation of the following:

1. The member has arthritis of the hip or knee, neuromuscular disease, or other medical condition affecting the member’s strength or mobility;
2. The member is unable to stand up from any chair at home; and
3. Once standing, the member has the ability to ambulate independently or with a properly fitted walker or cane.

Non-Covered Services

1. Seat lift mechanisms that operate by spring release mechanism are not covered because they are not the community standard of care and pose a risk to members with limited strength.
2. Although a seat lift mechanism may be covered, the chair for which the mechanism is intended is not covered because it is furniture rather than medical equipment.
3. The following items are not covered because they are home or vehicle modifications, not Durable Medical Equipment (DME):
   1. Vehicle lifts
   2. Platform lifts
   3. Stair lifts
   4. Elevators
   5. Wheelchair lifts
   6. Ramps
   7. Ceiling lifts
   8. Wall mounted lifts

Authorization

Authorization is required for any rental or purchase of all lift mechanisms. Authorization is required for any rental or purchase of a patient lift when the patient’s current lift, regardless of lift type, is less than five years old. Refer to the Non-Mobility Equipment Repairs section for authorization requirements for repairs to lift equipment.

For all requests for patient lifts, documentation must include the following:

1. Member weight and height, and general strength and age of primary caretaker
2. Documentation of the medical condition that requires the specific kind of lift requested
3. A description of the current method of transfer and why it does not meet the member’s needs
4. Description of how the lift will be used in critical areas of the residence
5. The plan of care
6. Documentation of satisfactory member and caretaker use of the lift
7. Documentation that the lift will fit in all necessary areas of the home
8. Less costly alternatives considered and why they were rejected

Billing

1. All hydraulic/mechanical/electric lifts include a seat or sling with initial dispensing. Do not bill separately.
2. Use the 837P professional electronic claim format.
3. Report the ordering provider in the “Other Provider Types” section of the claim.
4. If the member has Medicare, PrimeWest Health will pay only the deductible/co-insurance on any item for which Medicare made payment, regardless of any PrimeWest Health prior authorization.
5. If the member has Medicare, any items for which Medicare denies payment must meet PrimeWest Health coverage and authorization requirements.
6. Shipping/delivery costs are included in the PrimeWest Health maximum allowable payment and may not be separately billed to PrimeWest Health or the member.
7. Patient lifts and seat lift mechanisms are expected to serve the member for at least five years. If a device is stolen or damaged beyond repair, a replacement device may be covered with authorization. Equipment should not be replaced if still usable and meeting the patient’s needs after five years.

Positioning Seats for Use in Homes

Positioning seats for use in homes are covered for members with special orthopedic/medical needs during essential activities of daily living (ADLs) that cannot be met using conventional chairs or with needs that make conventional chairs medically inappropriate. A positioning seat may be medically necessary for a member with an inability to maintain an unsupported sitting position independently, which is caused by a medical condition such as any of the following (list is not all-inclusive):

1. Severe head and trunk instability
2. Severe hypotonicity, hypertonicity, spasticity, or muscle spasm that results in uncontrollable movement and position changes
3. Severe seizure activity that results in uncontrollable movement and position changes
4. Orthopedic condition, such as curvature of the spine, which interferes with proper positioning

Document the member’s current height and weight, and the weight capacity for the requested seat.

Non-Covered Services

1. Car seats when used simply to prevent injury to a child as required by law and community practice are not medically necessary
2. Car seats for members who use mobility devices with positioning/support attachments, and whose primary caregiver has a van equipped for wheelchair transportation are a duplication of service
3. Car seats for children who do not require positioning assistance
4. Positioning equipment requested to meet behavioral needs rather than positioning needs
5. Cervical rolls or pillows are not medically necessary
6. Feeding chairs/high chairs for members without significant positioning needs due to a medical condition are not medically necessary
7. Positioning seats, including feeding chairs/high chairs, for home use for members who use mobility devices with positioning/support attachments are a duplication of service
8. Furniture that is marketed to or useful to the general population, such as recliners, is not medically necessary and is not Durable Medical Equipment (DME)
9. Heat and massage cushion pads/recliners are not medically necessary and are not DME
10. Pillows designed to reduce allergens are not medically necessary and are not DME
11. Vehicle restraint belts or harnesses except where part of a covered positioning seat are a duplication of services

Authorization

Authorization is not required. Providers are expected to maintain documentation in the member’s file supporting need for equipment provided.

Billing

1. Use the 837P professional claim format.
2. Bill purchase of all reflux wedges and positioning cushions/pillows/wedges using E0190 and modifier NU unless a more specific code has been assigned by the Medicare Pricing, Data Analysis, and Coding (PDAC).
3. Bill replacement of accessories for a patient-owned positioning pillow using E0190 and modifier RB unless a more specific code has been assigned by the PDAC.
4. Bill purchase of all positioning seats for home or vehicle use using T5001 and modifier NU unless a more specific code has been assigned by the PDAC.
5. Positioning equipment that requires an authorization must be billed on a separate claim from equipment/supplies that do not require authorization.
6. The HCPCS code and modifiers must match the authorization.
7. If authorization is not required, the electronic claim must include the manufacturer’s invoice or price list as an attachment.

Billing

1. Use the correct Healthcare Common Procedure Coding System (HCPCS) code and the modifier NU or RR.
2. Make sure the HCPCS code, modifiers, and description match the authorization, if appropriate.
3. Use the 837P professional claim format.

Positive Airway Pressure (PAP) for Treatment of Obstructive Sleep Apnea

Continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) devices are used for treatment of obstructive sleep apnea.

Eligible Members

Positive airway pressure (PAP) devices and related supplies are covered for eligible members with a diagnosis of obstructive sleep apnea made by a physician with experience diagnosing and treating sleep apnea, using a sleep study.

Covered Services

Codes: E0470, E0601, A4604, A7027 – A7039, A7044 – A7046

CPAP/BiPAP Device Coverage

Providers may dispense a CPAP device for the first three months’ rental based on a physician’s order that includes a diagnosis of obstructive sleep apnea. During the 6^th to 12^th week of treatment, the supplier must verify that the member is complying with the ordered therapy. If the member has not achieved compliance by the 12^th week, but has demonstrated use of the CPAP device, PrimeWest Health will continue to cover the CPAP device for an additional eight weeks. During the additional eight-week period, compliance is defined as use of the CPAP device for four or more hours per 24-hour period for 70 percent of days. If the member has not achieved compliance after the additional eight weeks, the rental should end and the provider should take the equipment back.

PrimeWest Health will pay for rental of a BiPAP device without backup rate for members with obstructive sleep apnea when there has been a failed trial of a CPAP device or if there is a medical contraindication to CPAP. During the 6^th to 12^th week of treatment, the supplier must verify that the member is complying with the ordered therapy. If the member has not achieved compliance by the 12^th week, but has demonstrated use of the BiPAP device, PrimeWest Health will continue to cover the BiPAP device for an additional eight weeks. During the additional eight-week period, compliance is defined as use of the BiPAP device for four or more hours per 24-hour period for 70 percent of days. If the member has not achieved compliance after the additional eight weeks, the rental should end and the provider should take the equipment back.

PrimeWest Health will pay for the purchase of a CPAP or BiPAP device if the member has third-party insurance that requires purchase rather than rental.

Before dispensing masks or other supplies, providers must verify with the member that the CPAP and BiPAP device is still in use, and that the replacement of the supply is necessary because the existing supply is damaged or otherwise worn out.

CPAP (E0601)

Authorization is required for out-of-network providers before providing the service.

Members are limited to one CPAP every five years.

Provide documentation of the following:

1. Diagnosis
2. Sleep study
3. Contracted providers should also include: statement from the physician of use of CPAP by the member and effectiveness

Included with rental: Compressor, manometer, CPAP valve (if separate from mask), filters, fuses, instruction manual, carrying case, and a disconnection alarm (if needed).

Continuous Positive Airway Pressure (CPAP) Supply Limitations

Continuous Positive Airway Pressure (CPAP) Supply Limitations
Healthcare Common Procedure Coding System (HCPCS) Code	Description	Minnesota Senior Health Options (MSHO)/Special Needs BasicCare (SNBC) Limitations	Medical Assistance (Medicaid) Limitations
A4604	Tubing with integrated heating element	1 per 3 months	4 per month
A7027	Combination oral/nasal mask	1 per 3 months	3 per year
A7028	Oral cushion for combination oral/nasal mask, replacement, only each	2 per month	1 per month
A7029	Nasal pillows for combination oral/nasal mask, replacement only, pair	2 per month	2 per month
A7030	Full face mask used with positive airway pressure device	1 per 3 months	3 per year
A7031	Full mask interface, replacement for full face mask	1 per month	2 per month
A7032	Cushion for use on nasal mask interface, replacement only	2 per month	2 per month
A7033	Pillow for use only on nasal cannula type interface	2 per month	2 per month
A7034	Nasal interface (mask or cannula type)	1 per 3 months	3 per year
A7035	Headgear	1 per 6 months	3 per year
A7036	Chinstrap	1 per 6 months	1 per 6 months
A7037	Tubing	1 per 3 months	1 per month
A7038	Filter, disposable	2 per month	2 per month
A7039	Filter, non-disposable	1 per 6 months	3 per year
A7044	Oral interface		3 per year
A7045	Exhalation port with or without swivel		1 per 6 months
A7046	Water chamber for humidifier	1 per 6 months	5 per month

Bill separately: Replacement parts, tubing, head gear, and mask

BiPAP (E0470)

Authorization is required for out-of-network providers before providing the service.

Provide documentation of the following:

1. Diagnosis
2. Sleep study, including response to CPAP
3. Documentation of any day time symptoms
4. Contracted providers should also include: statement from the physician of use of BiPAP by the member and effectiveness

Included with rental/purchase: Compressor unit, filters, power cord, fuses, permanent circuit, swivel adapters, and instruction manual.

Bill separately: Humidification device, mask, and head gear

Non-Covered Services

A carrying case is a non-covered convenience item and is not medically necessary.

A CPAP device is not covered after the third month unless the supplier has verified patient compliance.

For members requiring a BiPAP device with backup rate or for members requiring CPAP or BiPAP devices who do not have obstructive sleep apnea, refer to the Respiratory Equipment section.

Billing

Refer to the following when billing for positive airway pressure devices:

1. Positive airway pressure devices are capped rental only unless a primary payer requires purchase.
2. Use X12 Batch or MN–ITS 837P Professional electronic claim.
3. Report the ordering provider in the “Other Provider Types” section of the MN–ITS interactive claim.
4. If the member has Medicare, PrimeWest Health will pay the deductible or co-insurance on any units for which Medicare made payment. Any units for which Medicare denies payment must meet MHCP quantity and coverage limits.
5. Bill the first three months using modifier RR and modifiers KH, KI, or KJ as appropriate.
6. When billing for rental after the first three months, use modifiers RR, modifier KJ if appropriate, and modifier KX if documentation in the file supports that the supplier has verified member compliance with treatment. Do not use modifier KX if the supplier has not verified compliance or if the supplier has information that the member is not compliant with treatment except as described above.
7. PrimeWest Health will deny claims for rental past the first three months unless the RR and KX modifiers are present to indicate member compliance with treatment.
8. Shipping and delivery costs are included in the PrimeWest Health maximum allowable payment. Do not bill either MHCP or the member separately for these costs.
9. PAP devices are expected to serve the member for at least five years. If a device is stolen or damaged beyond repair, a replacement device may be covered. Submit a claim with a Claim Attachment Criteria explaining why a replacement is required.

Pressure Reducing Support Surfaces

Pressure reducing support surfaces are used to prevent and treat pressure sores/decubitus ulcers.

Support surface products are divided into three groups.

Eligible Members

Pressure reducing support surfaces are covered for eligible members who do not live in nursing facilities.

Covered Services

Group 1

Codes: A4640, E0181 – E0189, E0196 – E0199 (bed overlays such as static air mattress overlays, etc.)

Authorization is not required. However, the medical supplier must have filed the following documentation:

1. Member is completely immobile
2. Member cannot independently make changes in body position significantly enough to alleviate pressure and has one of the following conditions:
   1. Current pressure ulcer on the trunk or pelvis
   2. History of pressure ulcer on the trunk or pelvis
   3. Impaired nutritional status
   4. Fecal or urinary incontinence
   5. Altered sensory perception
   6. Compromised circulatory status

Group 2

Codes: E0193: powered air flotation bed (low air loss) therapy; E0277: powered pressure-reducing air mattress; E0371: non-powered advanced pressure reducing overlay for mattress, standard mattress length and width; E0372: powered air overlay for mattress, standard mattress length and width; E0373: non-powered advanced pressure reducing mattress

Authorization is always required. Provide documentation of the following with the request:

1. The member’s attending physician must order based on a comprehensive assessment and evaluation of the member after conservative treatment has been tried without success. The physician must direct the home treatment regimen and reevaluate and re-certify the need for the bed every six months. Member must have healing as the goal of treatment and any one of the following:

1. Multiple stage II pressure ulcers located on the trunk or pelvis; member has been on a comprehensive ulcer treatment plan for at least the past month and has had poor response to treatment; and, member has used lower level support surface and ulcers have worsened
2. Large stage III or IV pressure ulcer(s) on the trunk or pelvis and the member cannot be positioned off the ulcer areas with a comprehensive treatment plan
3. Recent mycutaneous flap or skin graft for pressure ulcer on the trunk or pelvis and the member has been on a pressure reducing support surface immediately prior to discharge from a hospital or long-term care facility (LTCF) (surgery within past 60 days) and comprehensive treatment plan
4. Member has been on a group 2 or 3 support surface immediately prior to a recent discharge from a hospital or LTCF (discharge within past 30 days) and comprehensive treatment plan
5. After six months on a group 2 support surface and there has been no improvement in the member’s condition, alternative treatments must be considered before additional monthly rental will be authorized

Group 3

Code: E0194 (air fluidized beds)

Authorization is always required. Documentation of the following should be provided with the request:

1. The member’s attending physician must order the surface based on a comprehensive assessment and evaluation of the member after conservative treatment has been tried without success. The physician must direct the home treatment regimen and reevaluate and re-certify the need for the bed every six months. Member must have healing as the goal of treatment and any one of the following :
   1. Stage III or IV pressure sore on the trunk or pelvis, comprehensive treatment plan for the pressure sore and response to that treatment and documentation indicating the following:
   2. What other alternative equipment has been considered and why they were ruled out
   3. Is the member bedridden or chair bound as a result of severely limited mobility?
   4. After six months on a group 3 support surface and there has been no improvement in the member’s condition, alternative treatments must be considered before additional monthly rental will be authorized (i.e., wound vac, wound warm-up therapy, dressings with silver or other additives).
   5. List of co-morbidities or list of co-existing conditions (not covered with co-existing pulmonary disease)

Documentation, All Groups

A comprehensive treatment plan must be in place for any of the support surface products to be covered. This includes the following:

1. Education of the member and caregiver on prevention and management of pressure ulcers
2. History of conservative treatment
3. Regular assessment by a physician or other licensed practitioner
4. Appropriate turning and positioning
5. Appropriate management of moisture/incontinence
6. Nutritional assessment and intervention
7. Baseline albumin and pre-albumin levels, with tests repeated as necessary
8. Necessary medications when infection is present
9. Treatment plan of care of the wound
10. Indication that the home can accommodate this equipment

Authorization requests must include the following:

1. Physician order
2. Member information: diagnosis, height, weight, mental status, mobility, nutritional status, continence, activity level, care setting, turning surface, and medications
3. Wound description: size, stage, location, wound bed color, texture, drainage, and surgery dates
4. Therapies: treatment plan

Prosthetics and Orthotics

Definitions

Affiliate: A person who, directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, the ordering physician or consultant.

Physiatrist: A physician who specializes in physical medicine or who possesses specialized knowledge of rehabilitation and who is certified by the American Board of Physical Medicine and Rehabilitation (ABPMR).

Prosthetic or Orthotic Device: An artificial device, as defined by Medicare, to replace a missing or nonfunctional body part, to prevent or correct a physical deformity or malfunction, or to support a deformed or weak body part.

Criteria

A prosthetic or orthotic must be prescribed by one of the following:

1. A physician who is knowledgeable in orthopedics or physiatry
2. A physician in consultation with an orthopedist, physiatrist, physical therapist (PT), or occupational therapist (OT)
3. A podiatrist within the scope of their profession. PrimeWest Health covers podiatrist services to treat below the knee.

Medical Supplies and Equipment; Prostheses and Orthoses Medical Equipment/Supplies

Face-to-Face Encounter for Some Durable Medical Equipment (DME), Effective October 1, 2013
Section 302(a)(2) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) added Section 1834 (a)(1)(E)(iv) to the Act, which provides that payment may not be made for a covered item consisting of a motorized or power wheelchair unless a physician (as defined in section 1861[r][1] of the Act, or a physician assistant [PA], nurse practitioner [NP], or Clinical Nurse Specialist [CNS] as the terms are defined in Section 1861[aa][5] of the Act) has conducted a face-to-face examination of the beneficiary and written a prescription for the item.

The face-to-face encounter must be within six months before ordering or on the date of ordering. The documentation must show that the member was evaluated and/or treated for a condition that supports the DME item(s) ordered. 

For contracted providers, PrimeWest Health will allow the rental or purchase without an authorization and face-to-face encounter documentation for the following codes:

1. Geri Chair: E1031
2. Transport Chair: E1037, E1038, E1039
3. Manual Wheelchairs: K0001, K0002, K0003, K0004

Providers must get authorization for all equipment and supplies where authorization is indicated. Authorization is required for the following general areas:

1. All wheelchairs: When purchased, rented, or for use in nursing facilities.
2. Repairs to equipment (if parts and labor are more than $1,000). Specify who owns the equipment.
3. E1399 is the unspecified equipment code. This code is to be used only when no specific, descriptive HCPCS code is assigned.

Prostheses and Orthoses

Providers must request authorization for prostheses and orthoses (orthotics) when the cumulative cost exceeds $3,000.

A breast prosthetic is covered for members who have had a mastectomy or other conditions that result in absence or defect of the breast. Authorization is not required for these items unless cost is greater than $3,000. PrimeWest Health covers only one breast prosthetic per side for members who have undergone bilateral mastectomies. Use the following HCPCS code descriptions when evaluating the member.

• Mastectomy bras without integrated prosthesis form (L8000) and with integrated prosthesis form (L8001 and L8002) come in various materials and sizes to fit patients who have undergone a mastectomy.
• A mastectomy sleeve (L8010) is covered for members with post-mastectomy lymphedema.
• An external breast prosthesis garment (L8015) is covered for the postoperative period before a permanent breast prosthetic, or as an alternative to a mastectomy bra and breast prosthetic.
• A mastectomy bra (L8000) is covered for members with mastectomy form (L8020) or silicone breast prosthetic without integrated adhesive (L8030) when the pocket of the bra is used to hold the prosthetic.
• PrimeWest Health covers silicone breast prosthetics with integrated adhesives (L8031), prefabricated and custom nipple prosthetics (L8032 and L8033), and custom breast prosthetics (L8035). Authorization is required for custom breast and nipple prosthetics if cost is greater than $3,000. Documentation must clearly articulate why prefabricated prosthetics do not satisfy the needs of the member. HCPCS code L8039 should only be used when a breast prosthetic is not described by a more specific HCPCS code (L8000 – L8035).

Authorization

Authorization is required when the cumulative costs are $3,000 or greater, for contracted providers (out-of-network providers require authorization before providing the service, regardless of cost). Request the authorization for the base item only, but document all add-on items to allow the reviewer to have an overall picture of the item.

Authorization is always required for Standers Orthotics for thoracic-hip-knee-ankle-orthotic (THKAO), mobility frame, and THKAO standing frame, regardless of price. Provide documentation indicating the medical need for this type of orthotic (see Standers or Standing Frames section for more information).

Authorization is required for all sexual dysfunction prosthetics

Authorization is always required for implantable prosthetics (L8609, L8614, L8619); artificial cornea, cochlear device, and cochlear implant external speech processor, replacement. This is regardless of price. Provide documentation indicating the medical need for this type of prosthetic.

For all authorization requests:

1. Submit any add-on items with specific codes without authorization to PrimeWest Health for processing after the base item has been approved for medical necessity
2. Request replacement of a temporary prosthetic if less than three months old, regardless of price
3. Request replacement of a permanent prosthetic if less than three years old, regardless of price

Lower Limb Prosthetics

Overview

Lower limb prosthetics are used to restore ambulation to people with missing or amputated legs.

Third Party Liability (TPL) and Medicare

Providers must meet any provider criteria, including accreditation, for third party insurance coverage or for Medicare coverage in order to assist members for whom PrimeWest Health is not the primary payer.

PrimeWest Health quantity limits and thresholds apply to all members unless only the Medicare co-insurance or deductible is requested.

Covered Services

All Covered Lower Limb Prosthetics

A lower limb prosthetic must be prescribed by an enrolled PrimeWest Health provider. The provider must be:

• A physician, physician assistant, or advance practice registered nurse who is knowledgeable in orthopedics, physiatry, or vascular surgery
• A physician, physician assistant, or advance practice registered nurse in consultation with an orthopedist, physiatrist, or physical therapist
• A podiatrist within the scope of their professional practice (PrimeWest Health covers podiatrist services to treat conditions below the knee)

Evaluation

Evaluation of the member’s functional ability is required. For members with existing prostheses for whom a similar replacement is requested, evaluation can be based on the member’s history and current condition. For members for whom a first prosthesis is requested or for whom a significantly different prosthetic is requested, evaluation must be based on clinical observation.

Evaluations must be performed by a professional who is certified by the American Board for Certification in Orthotics, Prosthetics & Pedorthics (ABCOP) or who has similar training and expertise.

Use the following functional levels in the evaluation. Provide specific information about the member’s ambulation history, performance, and activities of daily living (ADL) to support assignment of an individual to a functional level. Note that these functional level definitions are not identical to the Medicare definitions. (For dual eligible members, if billing under the Medicare coverage, documentation must meet Medicare definitions)

1. Level 0: The member does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance the quality of life or mobility
2. Level 1: The member has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at a fixed cadence. Limited or unlimited household ambulator.
3. Level 2: The member has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs, or uneven surfaces. Limited community ambulatory.
4. Level 3: The member has the ability to ambulate over significant distances and over uneven surfaces. Unlimited community ambulator.
5. Level 4: The member has the ability for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. The member has a demonstrated need for ambulation requiring variable cadence over at least 400 continuous yards or a demonstrated need for regular ambulation on uneven terrain. Unlimited community ambulator with especially rigorous demands.

Specific Additions to Lower Limb Prosthetics

Feet and Ankles

1. An external keel SACH foot (L5970) or single axis ankle or foot (L5974) may be medically necessary for members whose functional level is 1 or above.
2. An energy storing foot (L5976) may be medically necessary for members whose functional level is 2 or above.
3. An axial rotation ankle unit (L5982-L5986) may be medically necessary for members whose functional level is 2 or above.
4. A microprocessor-controlled ankle foot system (L5973) may be medically necessary for members whose functional level is 3 or above.
5. A power assist ankle-foot or ankle system (L5969), multiaxial ankle with swing phase active dorsiflexion feature (L5968), dynamic response foot with multi-axial ankle (L5979), flex foot system (L5980), flex-walk system or equal (L5981), or shank foot system with vertical loading pylon (L5987) may be medically necessary for members whose functional level is 3 or above.

Knees

1. A pneumatic knee (L5614, L5822, L5830-L5840) may be medically necessary for members whose functional level is 2 or above.
2. A knee with stance phase microprocessor control feature (L5858) may be medically necessary for highly motivated members whose functional level is 2 or above.
3. A high activity knee control frame (L5930) may be medically necessary for members whose functional level is 3 or above, or for members whose weight requires the increased strength of this kind of frame.
4. A fluid/hydraulic knee (L5610, L5613, L5614, L5722-L5780, L5814, L5824-L5828, L5848) may be medically necessary for members whose functional level is 3 or above.
5. A knee with powered and programmable flexion/extension assist control (L5859) may be medically necessary for highly motivated recipients whose functional level is 3 or above who have a documented comorbidity in their sound limb or spine, or for bilateral amputees.
6. A knee with swing and stance phase microprocessor control feature (L5856) may be medically necessary for members whose functional level is 3 or above.
7. Other knee systems (L5611, L5616, L5710-L5718, L5810-L5818) may be medically necessary for members whose functional level is 1 or above.

Hips

A pneumatic or hydraulic polycentric hip joint (L5961) may be medically necessary for highly motivated members whose functional level is 2 or above.

Additional Criteria

Vacuum suspension system (L5781 or L5782) may be medically necessary for functional level 2 and above.

Osseointegrated External Prosthetic Connectors (L5991)

Osseointegrated external prosthetic connectors, components of bone-anchored prosthetic devices, are covered with authorization if all of the following criteria are met:

• The member has transfemoral, transhumeral, or transtibial amputation; and
• The member has failed to receive benefit from prosthetic devices with sockets or the member is not expected to tolerate socket use due to one of the following:
  • A short stump preventing use of a socket prosthetic device; or
  • Extensive skin grafting; or
  • Recurrent skin infections and ulcerations in the socket contact area; or
  • Restricted mobility; or
  • Socket retention problems; or
  • Soft tissue scarring; or
  • Volume fluctuation in the stump; and
• The member has the cardiovascular, cognitive, and physical ability to use the device; and
• The member does not have a comorbidity that may impede with functioning of the device; and
• Documentation articulates reasonable likelihood of improved mobility with the device instead of a standard prosthetic; and
• Documentation articulates need for mobility and how the device enhances the member’s ability to perform ADLs; and
• Consideration of less costly alternatives; and
• A trial demonstrates the member is able to use the device.

Osseointegrated external prosthetic connectors are contraindicated for any of the following:

• Atypical member skeletal anatomy which may impede with functioning of the device; and
• Incomplete member skeletal growth; and
• The member has a concurrent diagnosis of one of the following:
  • Active infection or dormant bacteria; or
  • Diabetic mellitus with complications; or
  • Metabolic bone disease or metastatic lesions in the residual femur; or
  • Neuropathy or neuropathic diseases and severe phantom pain; or
  • Severe peripheral vascular disease; or
• Skin disorders involving the residual limb; and
• The member has less than 2 millimeters of remaining cortex bone available around the implant, if implanted; and
• The member’s body weight is greater than 220 pounds (or 100 kilograms); and
• The member is older than 65 years or younger than 22 years; and
• The member is pregnant; and
• The member has osteoporosis.

Complete skeletal growth is defined as the finding of generally closed epiphyseal zones through X-rays. Atypical skeletal anatomy includes but is not limited to conditions which are not amenable to device insertion, development anomalies, and skeletal dimensions outside of the defined interval.

Upper Limb Prostheses

Codes: L6000 – L7259, L7400 – L7499, L8400 – L8499

Upper limb prosthetics are considered medically necessary for treatment of amputation or congenital birth defects in upper extremities.

Medical records must include the following:

• Reason for amputation
• Date of amputation
• Status of current limb
• Description of prosthetic being provided
• Which ADLs are affected and how they are impacted
• Functional capabilities before and after amputation
• Use the following categories for upper limb prosthetics when evaluating the member. Provide specific information about the member’s ambulation history, performance, and ADLs to support assignment of a particular device.

Passive Prostheses

Passive prostheses do not move on their own, are lightweight, and enhance the member’s condition by stabilizing or carrying objects. A passive upper extremity prosthetic is covered for members if all of the following criteria are met:

• The member is an amputee or has a congenital limb deficiency or absence of limb; and
• The member has the cognitive ability and desire to perform ADLs using the device; and
• The member’s evaluation demonstrates the anticipated functioning goals using the device to accomplish daily tasks, appropriate to the member’s condition, in a reasonable time period; and
• The member is cognitively, developmentally, or physically unable to use a body-powered prosthetic and is able to use the passive prosthetic; and
• The member is able to lock the prosthetic in place or, if a child, with the assistance of a parent or caregiver; and
• The device is the least costly alternative that meets the member’s medical needs.

Body-Powered Prostheses

Body-powered prostheses use body movements to control the device. A body-powered upper extremity prosthetic is covered for members if all of the following criteria are met:

• The member is an amputee or has a congenital limb deficiency or absence of limb; and
• The member has the cognitive and musculoskeletal ability and desire to perform ADLs using the device; and
• The member’s evaluation demonstrates the anticipated functioning goals using the device to accomplish daily tasks, appropriate to the member’s condition, in a reasonable time period; and
• A passive device does not meet the member’s functional needs to perform daily tasks; and
• The member does not have a comorbidity that may impede with functioning of the device; and
• The device is the least costly alternative that meets the member’s medical needs.

Myoelectric or Hybrid Prostheses

Myoelectric prostheses use electromyographic signals in muscle contractions to control the device. A myoelectric or hybrid upper extremity prosthetic is covered for members if all of the following criteria are met:

• The member is an amputee or has a congenital limb deficiency or absence of limb; and
• The member has the cognitive and musculoskeletal ability and desire to perform ADLs using the device; and
• The member’s evaluation demonstrates the anticipated functioning goals using the device to accomplish daily tasks, appropriate to the member’s condition, in a reasonable time period; and
• A passive or body-powered device does not meet the member’s functional needs to perform daily tasks; and
• The muscle to which the electrode is attached generates sufficient microvoltage to operate the device; and
• Documentation establishes that the member’s environmental factors, including wet environments, do not contraindicate using the device.

Supplies for Prostheses

Codes: L5618 – L5707, L5962, L5964, L5966, L6031, L6883 – L6885, L8400 – L8499

PrimeWest Health covers supplies for prosthetic devices. Supplies include sockets, test sockets, socket inserts, liners, suspension sleeves, sheaths, shrinkers, socks, and accessories. Supplies are covered if they are medically necessary and are required for functioning of the prosthetic device. Providers must document medical necessity and that the supply or replacement item is required for device functioning. The following list of supplies does not include all supplies covered by PrimeWest Health. The reasonable useful lifetime (RUL) for durable medical equipment (DME) applies to prosthetic supplies. Refer to the Medical Supply Coverage Guide for information on quantity limits by HCPCS code.

• Test sockets (L5618 to L5628, L6029, L6680 to L6684) are used to determine optimal fit and interface between the member’s skin at the residual limb and the material of the device. Multiple test sockets may be required to determine optimal fit as the residual limb stabilizes following amputation. PrimeWest Health covers two test sockets per prosthetic device. Authorization is required for excess quantities.
• Sockets (L5629 to L5632, L5634, L5636 to L5640, L5642 to L5653) are the part of the prosthetic device that fits around the residual limb and to which components and additions are attached. The socket must be precisely measured to ensure proper control and stability. Designs and features of sockets vary. Some socket designs include a flexible inner socket with an external frame or strapping (L5643, L5645, L5651). Some sockets have a release button to assist in removal of the prosthetic device. PrimeWest Health covers one socket per member-owned prosthetic device per year when the original item no longer functions. Authorization is required for excess quantities.
• Total contact sockets (L5637, L5650) fully interface with the residual limb and allow more surface area to bear weight against the prosthetic device. Air cushion sockets (L5646, L5648) are used for active ambulators and running. Suction sockets (L5647) usually have a silicone interface that creates a vacuum from natural properties as the socket is worn and weight placed against the prosthetic device. Ischial containment sockets (L5649) are sockets for above-knee amputations that contain the ischial tuberosity within the socket.
• Socket inserts (L5654 to L5658, L5661, L5665) serve as the interface between the residual limb and the prosthetic device. Socket inserts aid in the protection of fragile skin of the residual limb while compensating for changes in limb volume. Some prosthetic devices fit comfortably without use of a socket insert. PrimeWest Health covers one socket insert per member-owned prosthetic device per year when the original item no longer functions. Authorization is required for excess quantities.
• Liners (L5673, L5679) are soft sleeves that are worn over the residual limb and inside the prosthetic socket. Liners protect the residual limb, support suspension, increase comfort, and reduce the risk of skin irritation. PrimeWest Health covers two liners per member-owned prosthetic device per year when the original item no longer functions. Authorization is required for excess quantities.
• Molded distal cushions (L5668) are additions to liners that are fabricated from an impression of the residual stump.
• Thigh lacers (L5680, L5682) are corset-like cuffs that are attached to lower limb prosthetic devices, usually by two vertical sidebars to form a suspension system. Thigh lacers are for members who have undergone below-knee amputations and cannot tolerate full-contact pressure on their residual limb.
• Suspension sleeves (L5685) are used to hold the prosthetic device in place, distribute pressure, and reduce friction, rotation, and volume. Suspension locking mechanisms (L5671) use lanyards or pins that screw into the end of the socket to connect to the residual limb. Cuff suspension (L5666) allows the lower limb prosthetic device to make full contact with the residual limb by ensuring the integrity of the entire system. Cuffs are gripping devices that hold the residual limb below the knee.
• Single-axis knee joints (L5676) act as a door-and-hinge device that allows one-speed ambulation, is free swinging, and does not allow stance control. Polycentric knee joints (L5677) have multiple rotational axes that include four points of rotation attached by a linkage bar. They are stable in early stance and easy to flex in swing phase.
• Waist belts (L5688, L5690) are used to provide suspension support, primarily for members who have weak musculature or cannot tolerate other forms of suspension. Pelvic control belts (L5692, L5694) are used to maintain proper gait mechanics for members with above-knee prosthetics. Pelvic control sleeve suspension (L5695) is pulled over the residual limb and extends over the pelvis. Pelvic joints (L5696) are composed of single and multiple axes and are mounted in the front of the prosthetic device. They provide flexibility at the hip and allow ambulation. Pelvic bands (L5697) are broad bands or wrappings worn around the waist and from which the prosthetic device is attached.
• Molded-to-patient-model replacement sockets (L5700 to L5703, L6031, L6883 to L6885) are covered for member-owned prosthetic devices when the original item no longer functions. Documentation must clearly articulate why non-molded-to-patient sockets do not satisfy the needs of the member. Authorization is always required.
• Custom-shaped protective covers (L5704 to L5707) are protective coverings for prosthetic devices that are manufactured to match the length, size, and thickness of the member’s lost limb and are usually constructed to resemble human skin. Protective covers allow protection, shaping, and weatherproofing. Protective outer surface covering systems (L5962, L5964, L5966) are specialized coverings that are used against unusually harsh environments. Protective outer surface covering systems are not for use in typical environments. Protective coverings are non-cosmetic. PrimeWest Health covers one unit per member-owned prosthetic device per year when the original item no longer functions. Authorization is required for excess quantities.
• Textile products include sheaths, shrinkers, and socks. Sheaths (L8400, L8410, L8415, L8417) are protective garments that are worn against skin beneath a sock (L8420, L8430, L8435, L8470, L8480, L8485). Sheaths are used to reduce friction and provide comfort and moisture management. Shrinkers (L8440, L8460, L8465) are used to reduce swelling, shape the limb, and prepare the limb for prosthetic fitting.
• Authorization is always required for unlisted procedures for miscellaneous prosthetic services (L8499). HCPCS code L8499 should only be used when there is not a more specific HCPCS code. Documentation must clearly indicate the need for the unspecified procedure or service. Providers cannot bill noncovered services under miscellaneous HCPCS code L8499 or any other miscellaneous code. 

Non-Covered Services

• A prosthetic or orthotic device for which Medicare has denied the claim as not medically necessary.
• A device whose primary purpose is to serve as a convenience to a person caring for the member.
• A device that serves to address social and environmental factors and that does not directly address the member’s physical or mental health.
• A device that is supplied to the member by the physician who prescribed the device or by a provider who is an affiliate of the physician who prescribed the device.
• Repair costs for a prosthetic device that is under warranty.
• Repair costs for any rented prosthetic equipment.
• Repair or replacement costs for devices or parts within 90 days of the date of delivery.
• Lower limb prosthetics for members who have been found to have functional ability or potential functional ability of level 0.
• User-adjustable heel height feature (L5990) is considered not medically necessary.

Authorization

Prosthetic charges greater than $3,000 require a Service Authorization.

• Submit the prosthetic base Healthcare Common Procedure Coding System (HCPCS) code with appropriate modifiers on the first line of the authorization request if a new prosthetic is being requested.
• List all add-on items by HCPCS code with appropriate modifiers, quantity, and submitted charge.
• Documentation must address the member’s medical and functional need, and how the requested prosthetic meets those needs.
• Documentation must include the assessment of the member’s functional status, and how the member’s functional status relates to the need for the requested items.
• Documentation for purchase must establish that the requested device is the least costly appropriate way to meet the member’s needs.
• When requesting authorization for identical replacement of components on an existing prosthetic, it is not necessary to establish medical necessity for those components. Document that the component needs to be replaced and is not covered by a warranty.
• When requesting authorization for non-identical replacement of components on an existing prosthetic, document the medical necessity for the requested components.

Billing

• Use X12 Batch or the 837P professional electronic claim.
• Report the ordering provider.
• Shipping/delivery/set-up costs are included in the PrimeWest Health maximum allowable payment and may not be separately billed to PrimeWest Health or the member.
• PrimeWest Health will not pay claims for more units per line than are allowed by Medicare’s Medically Unlikely Edits (MUE). When billing for bilateral prosthetics where more units are required than are allowed by the MUE, the units must be billed on different lines, with modifiers NU RT and NU LT as appropriate.
• Prosthetic devices for which fabrication has begun but which have not been dispensed as of the date of the member’s termination from PrimeWest Health eligibility may be reimbursed on a prorated basis to the extent that customization renders all or part of the device unsuitable for use by someone else.
• When billing labor for repairs, specify the number of units and the hourly rate. Do not bill for setup and delivery, or for service calls that do not involve actual labor time for repairs.
• When billing for items approved on a prior authorization:
  • Submit one claim for all approved lines. Make sure the HCPCS codes, modifiers, and descriptions on the claim match the same information on the prior authorization.
  • Enter the authorization number in the authorization field for each line.

Devices for Bathing or Recreation

Devices for purposes of bathing or showering and for purposes of recreation are covered with authorization. PrimeWest Health covers a recreational device for purposes of performing physical activities including, but not limited to, running, biking, swimming, and maximizing the member’s limb function. The usual reasonable useful lifetime (RUL) of five years for durable medical equipment (DME) does not apply to artificial limbs. PrimeWest Health covers medically necessary repairs and replacements for parts and devices. Members cannot automatically obtain a new device if the original is still in working order. Members whose functional level is 2 or above are eligible for recreational prosthetics. Authorization is required for devices for recreation. Use modifier U2 for billing. Authorization is not required for initial devices for bathing or showering unless cost is greater than $3000. Use modifier U1 for billing. Bathing devices only require authorization if they are the member’s third device or cost greater than $3000. Authorization is required for subsequent new devices for replacing the member’s initial device for any purpose. It is the expectation of PrimeWest Health that devices for bathing or showering are nonelectronic and made from the least costly items and waterproof materials.

Non-Covered Services

1. Repair costs for a prosthetic or orthotic device purchased by PrimeWest Health that is covered under warranty, or repair costs for any rented orthotic or prosthetic equipment
2. A device that serves to address social and environmental factors and does not directly address the member’s physical or mental health
3. A device that is supplied to the member by the physician who prescribed the device, or by the consultant to the physician
4. A device that is supplied to the member by an affiliate of the physician who prescribed the devices, or of the consultant to the physician.

Respiratory Equipment (Suitable for 12 Hours or Less per Day)

Codes: E0470, E0471, E0472 (bi-level positive airway pressure [BiPAP])

Overview

Ventilators are used by members without spontaneous breathing or with limited or intermittent spontaneous breathing. Continuous Positive Airway Pressure (CPAP) and Bi-level Positive Airway Pressure (BiPAP) devices are used for spontaneously breathing recipients who require ventilation assistance.

Eligible Providers

The following providers may provide ventilators:

1. Medical suppliers
2. Pharmacies (CPAP and BiPAP equipment only)
3. Home health agencies
4. Indian Health Services
5. Federally Qualified Health Centers
6. Rural Health Clinics

Because ventilators are life-sustaining equipment, providers must do the following:

1. Conduct an in-home environmental assessment to confirm the member’s residence will safely accommodate the ventilator and auxiliary equipment, along with routine household appliances and activities. The assessment includes, but is not limited to, checking for grounded electrical outlets and functional smoke detectors, emergency protection planning, and escape route planning.
2. Train the member and caregivers in proper use of the ventilator, including infection control, alternative ventilation, and emergency ventilation procedures
3. Have 24-hour-per-day support for troubleshooting and ventilator exchange due to unresolved malfunction
4. Ensure critical alarms are appropriately set on the ventilator
5. Ensure a backup alarm system is in place for when the member is not directly observed by a fully trained caregiver
6. Perform periodic maintenance at least as frequently as recommended by the manufacturer

TPL and Medicare

Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist members for whom PrimeWest Health is not the primary payer.

PrimeWest Health quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.

Eligible Recipients

Respiratory equipment and related supplies are covered for eligible members with a diagnosis of restrictive thoracic disorders, severe chronic obstructive pulmonary disease, central sleep apnea, neuromuscular respiratory insufficiency, or other diagnoses which require ventilation assistance.

Covered Services

The following services are covered:

1. E0470 – E0472, E0600, E0601, A4604, A4605, A4614 – A4620, A7027 – A7039, and A7044 – A7046
2. BiPAP device for members with medical conditions that require ventilation assistance if the member has spontaneous respiration
3. CPAP device for members with breathing disorders other than obstructive sleep apnea (OSA) with authorization
4. BiPAP device with backup rate for members with OSA and co-existing breathing disorders. Both diagnosis codes must be on the claim.
5. Rental of a ventilator for members who have been determined by a physician to need a ventilator. Both a portable and a stationary ventilator may be covered when documentation establishes that a portable ventilator alone does not meet the member’s needs (codes E0465 and E0466). For example:
   1. The member requires the use of one type of respiratory device during a portion of the day and the use of a second device during another portion of the day (with documentation that both modalities cannot be served by a multi-function respiratory device).
   2. The member is wheelchair-bound and requires a respiratory assist device to be mounted to the wheelchair for use when out of the bed as well as the same type of device for use while in bed and without both pieces of equipment, the individual may be prone to medical complications, may be unable to achieve appropriate medical outcomes, or may not be able to use the medical equipment effectively.
6. For members with OSA, refer to DHS’s Positive Airway Pressure for OSA policy
7. Rental of the multifunction ventilator (E0467) is covered for members who would otherwise require both a portable and a stationary ventilator, but can be served by the multifunction ventilator alone. E0467 must be billed without another ventilator rental. In addition, the multifunction ventilator also has the capability of completing the nebulizer, oxygen, cough assist, and suction functions. All codes encompassed by E0467 are not separately reimbursable unless the member has oxygen needs over 6 liters per minute. If a member is utilizing the oxygen feature of the multifunction ventilator, providers must adhere to the requirements of the oxygen policy found in the Oxygen Equipment section of the MHCP Provider Manual, including supplying 12 hours of emergency gaseous oxygen at no additional charge.

Ventilators always require an authorization.

Authorization is required for the second ventilator when the member requires both a portable and a stationary device. Authorization requests must include a letter of medical necessity that addresses all the following criteria as applicable:

• Member-specific medical necessity. General statements of medical necessity that are not member-specific will not be accepted.
• Explanation of the member’s daily activities and ventilator needs during those activities. (Include transfer and mobility needs and caregiver assistance required.)
• Include an explanation of the member’s activities outside of the home including school, work, or other settings regularly frequented and any specific ventilator needs for travel.
• Include all pertinent diagnoses and ventilator settings (for example, dual settings or duration).
• Include any respiratory treatments or devices used and duration (for example, suction, oxygen, or other respiratory treatments).
• Explain the two different ventilators, what they are doing for the member, and why they are both required.
• Submit the most recent physician and or pulmonologist progress note.
• Submit documentation that you have addressed the following safety concerns about the second ventilator with the member or caregivers:
  • Conduct an in-home environmental assessment to confirm the member’s residence will safely accommodate the ventilator and auxiliary equipment, along with routine household appliances and activities. The assessment includes, but is not limited to, checking for grounded electrical outlets and functional smoke detectors, emergency protection planning, and escape route planning.
  • Train the member and caregivers in proper use of the ventilator, including infection control, alternative ventilation, and emergency ventilation procedures.
  • Have 24-hour-a-day support for troubleshooting and ventilator exchange due to unresolved malfunction.
  • Ensure critical alarms are appropriately set on the ventilator.
  • Ensure a backup alarm system is in place for when the member is not directly observed by a fully trained caregiver.
  • Perform periodic maintenance at least as frequently as recommended by the manufacturer.

Documentation must indicate the medical condition and how CPAP, BiPAP, or the ventilator is medically necessary for the member

Billing

Refer to the Medical Supply Coverage Guide for coverage information and limits on supplies not specified here.

When dispensing a device that can provide multiple levels of treatment (a device with CPAP, BiPAP, or ventilator modes) to a member, billing must be based on the member’s medical condition. Providers must have documentation from the prescriber that is sufficient to support the level of service for which the supplier is billing.

Included with initial CPAP or BiPAP dispensing

1. Carrying case
2. Compressor
3. CPAP valve (if separate from mask)
4. Disconnection alarm (if needed)
5. Filters
6. Fuses
7. Instruction manual
8. Power cord
9. Permanent circuits
10. Swivel adapters

Separately billable at initial CPAP or BiPAP dispensing

1. Head gear
2. Mask
3. Tubing
4. Humidification device

Included with ventilator rental

1. Battery
2. Breathing circuits
3. Carrying case
4. Cart
5. Electric cord
6. Exhaustion valves
7. High, low, and disconnect alarms
8. High-pressure hoses
9. IMV devices
10. PEEP valve
11. Pressure manometers
12. Spirometer (any kind)
13. Stand
14. Water traps

Separately billable from ventilator rental

1. Humidifier
2. Manual resuscitation bags
3. Oxygen
4. Oxygen analyzers

Other billing guidelines

1. Ventilators have been determined by the Centers for Medicare and Medicaid Services (CMS) to require frequent and substantial servicing. PrimeWest Health will not purchase ventilators, and rented ventilators do not convert to purchase.
2. CPAP and BiPAP equipment is capped rental only unless a primary payer requires purchase and authorization is obtained.
3. Use X12 Batch or MN–ITS 837P Professional electronic claim.
4. Report the ordering provider in the “Other Provider Types” section of the MN–ITS interactive claim.
5. If the member has Medicare, PrimeWest Health pays the deductible or co-insurance on any units for which Medicare made payment, regardless of any PrimeWest Health authorization.
6. Any items or units for which Medicare denies payment must meet PrimeWest Health quantity, coverage, and authorization limits.
7. Bill the first three months of CPAP or BiPAP equipment using modifier RR and modifiers KH, KI, or KJ as appropriate.
8. When billing for rental of CPAP or BiPAP equipment after the first three months, use modifiers RR; modifiers KH, KI, or KJ as appropriate; and modifier KX if documentation in the file supports that the supplier has verified member compliance with treatment. Do not use modifier KX if the supplier has not verified compliance or if the supplier has information that the member is not compliant with treatment except as described above.
9. PrimeWest Health will deny claims for CPAP or BiPAP rental past the first three months unless the RR and KX modifiers are present to indicate member compliance with treatment.
10. Shipping and delivery costs are included in the PrimeWest Health maximum allowable payment. Do not bill either PrimeWest Health or the member separately for these costs.
11. Refer to Non-Mobility Equipment Repairs for billing requirements for repairs and maintenance to member-owned equipment.
12. CPAP and BiPAP equipment is expected to serve the member for at least five years. If a device is stolen or damaged beyond repair, a replacement device may be covered with authorization. Submit a claim with a Claim Attachment Criteria explaining why a replacement is required.

Intermittent Positive Pressure Breathing (IPPB) Machine

Code: E0500

Robotic Arms and Assistive Technology

Overview

Assistive technology refers to equipment that assists members with severely limited use of their upper extremities in performing activities of daily living (ADLs) or instrumental activities of daily living (IADLs). ADLs include, but are not limited to, bathing, dressing, drinking, eating, hygiene activities and toileting, and other activities specified in the treatment plan. IADLs allow an individual to live independently and include, but are not limited to, accessing public transportation, food preparation, housekeeping, opening doors, shopping, and taking medication.

Assistive technology includes robotic arms and robotic assistive feeding devices. Robotic arms refer to powered devices that are attached to a member’s power wheelchair. Members control the robotic arm via a joystick. Robotic assistive feeding devices refer to powered devices that are placed on a flat surface and aid members in eating.

Eligible Providers

Robotic arm vendors must be enrolled as medical equipment providers. The following are eligible to provide robotic arms:

• Federally qualified health centers
• Home health agencies
• Hospitals
• Indian health services
• Medical suppliers
• Rural health clinics

Eligible Members

Assistive technology devices are covered for eligible members with a disability that severely restricts use of their upper extremities. PrimeWest Health covers only one type of assistive technology device per eligible member.

Potential diagnoses could include (but are not limited to):

• Amyotrophic lateral sclerosis (ALS)
• Arthrogryposis
• Cerebral palsy
• Multiple sclerosis
• Muscular dystrophy
• Parkinson’s disease
• Quadriplegia
• Spinal cord injury
• Spinal muscular atrophy
• Stroke

Covered Services

PrimeWest Health covers robotic arms and robotic assistive eating devices.  Assistive technology devices are coded as miscellaneous HCPCS code E1399. Use modifier U9 for robotic arms and modifier UA for robotic assistive feeding devices.

Robotic arms

Robotic arms are covered for members who have a condition that severely restricts use of their upper extremities and meet all of the following criteria:

• The member must be a full-time power wheelchair user; and
• Documentation indicates the member is unable to use both of their upper extremities against gravity, as evident by manual muscle testing; and
• Documentation shows the device will allow the member to be independent in one or more ADLs or IADLs
• A trial demonstrates the member is able to use the device

Robotic assistive feeding devices

Robotic assistive feeding devices are covered if all of the following are met:

• Documentation shows the member only requires a device to be independent in eating; and
• Documentation indicates the member is unable to use both of their upper extremities against gravity, as evident by manual muscle testing; or
• Documentation indicates the member has uncontrollable spastic movements in their arms which prevent them from eating independently; and
• A trial demonstrates the member is able to use the device.

Providers must use HCPCS code A9900 for robotic assistive feeding devices accessories that do not have a more appropriate HCPCS code. Dispensing of a robotic assistive feeding device includes the charging cable, placemat, plate, pressure switches, and utensils. PrimeWest Health covers additional placemats, plates, and utensils with authorization. Documentation must support the quantity requested.

Replacement charging cables and pressure switches are covered for member-owned devices when the original item no longer functions. Document in the medical record that the original item is no longer functional.

PrimeWest Health considers both a robotic arm and a robotic assistive feeding device as duplication of services for most members. PrimeWest Health only covers robotic assistive feeding devices for members with robotic arms if the member’s unique medical condition physically prevents them from effectively or safely using the robotic arm for eating. PrimeWest Health does not cover robotic assistive feeding devices for purposes of convenience.

PrimeWest Health reviews robotic assistive feeding devices for members with robotic arms only when documentation substantially demonstrates medical necessity. The review process is as follows:

• The provider and medical supplier evaluate the member’s medical needs, attach the robotic arm to the member’s power wheelchair, and provide necessary training and adjustments.
• The member uses the robotic arm in their usual living arrangement.
• PrimeWest Health receives and reviews the request for a robotic arm. If the robotic arm is approved, the device becomes the member’s property.
• The member continues using the robotic arm. If it becomes apparent that the member is unable to effectively or safely use the robotic arm for eating, and there is no expected improvement, then the provider and medical supplier evaluate the member’s medical needs for eating.
• Request for a robotic assistive feeding device is submitted. Documentation must include:
• Description of member’s unique medical condition that physically prevents them from effectively or safely using the robotic arm for eating; and
• Description of member’s use of the robotic arm for eating and how device use has failed to meet the member’s medical needs; and
• PrimeWest Health receives and reviews request for a robotic assistive feeding device.
• If the robotic assistive feeding device is approved, the device becomes the member’s property.

Providers must obtain documentation from the member or the member’s authorized representative acknowledging that the member understands the device may affect future requests for PCA or home care services before dispensing and billing for this item. The documentation must be made available to the Minnesota Department of Human Services (DHS) or its authorized agent upon request.

Noncovered Services

PrimeWest Health does not cover assistive technology devices that are not registered with the U.S. Food and Drug Administration.

Authorization

Prior authorization is required for all assistive technology devices. Submit authorization request and required documentation to PrimeWest Health. Requests for coverage are reviewed according to procedures for reviewing durable medical equipment (DME) requests. Coverage determinations are based upon a review of submitted case-specific information.

Documentation for authorization requests must include:

• Member’s diagnosis and clinical history
• Order
• Letter of medical necessity
• Face-to-face evaluation from physical or occupational therapist and and clinical notes
• Description of the member’s current medical services and treatments, including PCA or home care services
• Results of device trials in the clinic, including length of trial, and links to unedited trial videos of the member completing ADLs or other desired IADLs. Documentation must identify the ADLs and IADLs for which the device is requested. Providers must specifically address eating as an ADL during the device trial
• Description of member performance of ADLs during the trial period
• Consideration of less-costly alternatives including documentation stating why alternative devices are not appropriate for member’s condition and medical needs. If requesting a robotic arm, explain why robotic assistive feeding devices are not appropriate for the member's condition and medical needs
• A statement or acknowledgment from the member or their authorized representative that approval may affect future requests for PCA, CFSS, or other home care services
• A detailed list of products and accessories including manufacturer, model number, product description, and manufacturer’s suggested retail price (MSRP)

PrimeWest Health policy requires a three-month trial for robotic arms. Authorization is required for the purchase of robotic arms following the trial period. Trial periods must be initiated before requesting authorization and payment will only be provided upon the successful completion of the trial period. The review process is as follows:

• The provider and medical supplier evaluate the member’s medical needs, attach the device to the member’s power wheelchair, and provide necessary training and adjustments.
• The member uses the device in their usual living arrangement.
• During the three-month trial period, a request for purchase of the device must be submitted along with documentation from a physician or therapist illustrating ongoing, safe use of the device.
  • Requests for purchase may be submitted four weeks into the trial period, or later; however, purchase will only be effective after completion of the full three-month trial.
  • If during the trial period the member does not wish to convert the robotic arm to a purchase, the device must be detached and returned to the provider.
• PrimeWest Health receives and reviews requests for robotic arms according to procedures for reviewing DME. If the robotic arm is approved, the device becomes the member’s property.

Three-month trial periods are only required for robotic arms. Trials for all assistive technology must include links to unedited videos of the member using the device.

Billing

Providers are responsible for coordinating services. Bill assistive technology devices using HCPCS code E1399 for assistive technology and K0108 for accessories that do not have a more appropriate HCPCS code.

• Use modifier U9 with E1399 for robotic arms
• Use modifier UA with E1399 for robotic assistive feeding devices
• Assistive technology devices have a warranty period in which the manufacturer is to pay for maintenance and repair. MHCP will only reimburse for one month of rental while a device is being repaired.
• When adding a robotic arm to an existing mobility device, the provider is responsible for the replacement of the joystick and interface controls or electronics needed for the operation of the robotic arm.

Seizure Detection Devices

Eligible Members

Seizure detection devices are covered for PrimeWest Health members who have a medical diagnosis of convulsive seizure, who have active epilepsy, and who meet either of the following criteria:

• The device will likely assist in reducing bodily harm or death from convulsive seizures; or
• The device will provide data to the health care provider necessary to diagnose or treat a health condition of the member that causes the seizure activity

The device must be FDA approved.

Covered Services

Codes

A9279: Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components, and electronics, not otherwise classified. PrimeWest Health covers one device every five years. Bill using U2 modifier.

99454 (prior authorization required for monitoring): Remote monitoring of physiologic parameters, initial supply of devices with daily recordings or programmed alerts transmission, each 30 days. Bill using U2 modifier. 

Specialized Wound Treatment Technology

Specialized wound treatment technology is used to treat non-healing wounds.

Eligible Members

Specialized wound treatment technology may be medically necessary for eligible PrimeWest Health members with wounds that have not responded to standard wound treatment for at least a 30 – 60 day period. Negative Pressure Wound Therapy (NPWT) may be medically necessary for eligible PrimeWest Health members with wounds of less than 30 days duration if the patient is inpatient and preparing for discharge.

Covered Services

Codes (these are not all-inclusive codes)

E2402, A6550, A6551, K0743, K0744, K0745: Negative pressure wound therapy
E1399, A4649: Platelet rich plasma systems (e.g., AutoloGel system, Magellan)

The platelet-rich plasma centrifuge is not covered in long-term care facilities (LTCFs). Device-specific supplies (i.e., applicators, reagents) may be covered in LTCFs.

Negative Pressure Wound Therapy (NPWT) Pump (E2402)

Authorization is always required. Wound vac or NPWT will be considered when a wound does not respond to standard wound treatment for at least 30 to 60 days, except in the case of skin grafts and acute/trauma wounds.

For all wounds, the following documentation is needed and should be part of a comprehensive treatment plan:

1. Wound type, including etiology and stage when appropriate, date of onset and evaluation, previous wound care (dressings [moist, gel, impregnated], debridement, etc.), and assessments done by a licensed medical professional (every 30 days by doctor of medicine [MD], physician assistant [PA], doctor of osteopathy [DO], nurse practitioner [NP] is strongly recommended)
2. Weekly wound assessment and measurements (length, width, depth, color, exudates, odor, evidence of healing, tunneling, etc.). This should be done by nursing staff in the skilled facility or in the home setting.
3. Evaluation and provision for adequate nutritional status. Include both prealbumin and albumin levels. Ideally, albumin levels are 3.5 – 5. If albumin levels are below 3.5, specialized wound therapy may be approved if prealbumin levels are 20 – 40, show improvement over the previous 30 days, and if there is a nutritional plan in place written by an appropriate professional. Specialized wound therapy will not be authorized for albumin levels below 2.8. Baseline albumin and prealbumin levels are required and as medically necessary thereafter. If albumin levels are below 3.5, enteral nutritional support may be covered.
4. How is moisture and incontinence being addressed and managed?
5. Documentation of any compliance issues (refusal of dressing changes, smoking, poor nutritional choices, etc.) and how they are being addressed
6. Documentation of any underlying conditions (infections, etc.) that may hinder the healing process of the wound and how they are being corrected
7. Assessment of medications that may delay healing (steroids, immunosuppressant, etc.)
8. Evaluation of arterial sufficiency, when appropriate
9. Licensed professional (registered nurse [RN], licensed practical nurse [LPN], physical therapist [PT]) services in place for treatment in the home
10. Document how this request is appropriate for the type of wound being treated

For pressure ulcers and arterial ulcers, also document the following:

1. Whether moist wound environment was tried, for how long, and the outcome
2. Whether member is appropriately turned and positioned
3. Care plan for pressure management surface while the member is in bed or wheelchair
4. For chronic ulcers, how long the member has had this ulcer

For diabetic neuropathic ulcers, also document the following:

1. Whether moist wound environment was tried, for how long, and the outcome
2. Whether non-weight bearing or pressure reduction is in place and for how long. Appropriate offloading may include crutches, walkers, wheelchairs, custom shoes, depth shoes, shoe modifications, custom inserts, custom relief orthotic walkers, diabetic boots, forefoot and heel relief shoes, or total contact casts.
3. Whether blood glucose levels are monitored and if the member has a diabetes management program

For venous ulcers, also document the following:

1. Whether compression is in place—what is used, how long, and results

For acute/traumatic wounds, there should be an inpatient stay. Also document the following:

1. Date of wound and cause
2. Any evidence of healing in the last week
3. Whether NPWT was applied during inpatient stay
4. The member’s pre-existing condition(s)

For post-split thickness skin graft, also document the following:

1. What part of the body is the graft or flap (uneven surface, joint, bony prominence)
2. Whether NPWT was applied intraoperatively

Remember the following contraindications for the negative pressure wound therapy:

1. Untreated osteomyelitis within the vicinity of the wound
2. Presence in the wound of necrotic tissue with eschar, if debridement has not been attempted
3. Cancer present in the wound
4. Presence of a fistula to an organ or body cavity within the vicinity of the wound

Ongoing need of Wound Vac or NPWT: After initial approval, updated documentation is needed every 30 days while treatment continues to use NPWT. Every 30 days provide the following:

1. Weekly wound assessment and measurements
2. Treatment applied

Remember if NPWT is needed for more than four months, an alternate treatment might be needed.

AutoloGel System

Codes: E1399, A4649

Authorization is needed for PrimeWest Health members when the cost is more than $400.

The AutoloGel centrifuge is not covered in nursing facilities. Device-specific (e.g., applicators, reagents) may be covered in LTCFs.

Remember the following contraindications for AutoloGel System:

1. Active cancer at wound site
2. Chemotherapy within the past five years
3. Hematological disorder
4. Bleeding disorder
5. Perfusion to extremity of wound
6. Untreated osteomyelitis at wound site
7. Member being treated with Methotrexate
8. Allergy to beef or dairy

Non-Covered Services

1. Topical hyperbaric oxygen for the treatment of wounds is considered investigative due to lack of evidence demonstrating its impact in health outcome.
2. Electrical stimulation using low-intensity direct current, high voltage pulsed current, alternative current, and transcutaneous electrical stimulation for the treatment of wounds is considered investigative due to a lack of evidence demonstrating its impact on improved health outcomes.
3. Electrical stimulation for the treatment of wounds performed by the patient in the home setting is considered investigative due to a lack of evidence demonstrating its impact on improved health outcomes.
4. Electromagnetic therapy for the treatment of wounds is considered investigative due to a lack of evidence demonstrating its impact on improved health outcomes.
5. Non-contact ultrasound treatment for wounds is considered investigative due to a lack of evidence demonstrating its impact on improved health outcomes.
6. Electrochemical low-dose tissue oxygenation systems are considered investigative due to a lack of evidence demonstrating impact on improved health outcomes.

Skin Substitutes for Wound Care

Prior Authorization is needed for PrimeWest Health members.

Codes

• Q4100 – Q4108
• Q4110 – Q4118
• Q4121 – Q4128
• Q4130
• Q4132 – Q4143
• Q4145 – Q4171
• Q4173 – Q4198
• Q4200 – Q4206
• Q4208 – Q4222
• Q4226

Spirometers

Spirometers are pulmonary function tests used to measure the volume/flow of inhaled and exhaled air.

Codes

A9284: non-electronic
E0487: electronic

Only spirometers approved by the Food and Drug Administration (FDA) are covered. Do not use A9284 or E0487 for incentive spirometers.

Authorization

Authorization is not required. Payment is made only when the member has a respiratory or cardiovascular condition. Providers must maintain documentation of the following:

1. Statement detailing medical need for home monitoring, including specific patient orders
2. If electronic spirometer is supplied, explain why a non-electronic spirometer does not meet the member’s needs

Standers or Standing Frames

Codes: E0637, E0638, E0641, E0642

Eligible Members

Standers are covered for eligible PrimeWest Health members who:

1. Have little or no potential for walking
2. Cannot stand unassisted for appreciable amounts of time
3. Meet coverage criteria

Authorization

Authorization is always required. Provide documentation of the member, condition, therapy program, trial, and physical therapy assessment to include the following:

1. Diagnosis. Must have a diagnosis of an underlying medical condition that involves inability to walk or loss of walking ability.
2. For pediatric members, a stander can be considered for developmental delay in ambulation for members at least 2 years old, or can be considered for neurological impairment for members at least 1 year old
3. Age
4. Height (for pediatric members) and weight
5. Description of function (sitting ability, standing ability, mobility) documentation of standing tolerance
6. Description of transfers
7. How long this equipment is needed and frequency of proposed use
8. Document that the member is under the care of a rehab specialist or physician
9. Documentation that the caregiver is available and able to assist the member or that the member has normal upper extremity strength

If the member is currently in a nursing facility, authorization will be considered if requested as part of a discharge plan or if documentation establishes that there is sufficient space in the member’s room for the equipment, and that use of the stander will be part of the member’s care plan. All other criteria must be met.

The stander must be an integral part of a therapy program in the home with specific, measurable outcomes unique to the member in at least two of the following areas:

1. Improvement of respiratory function where the member has impaired respiratory function due to the medical condition that impairs walking ability
2. Prevention of contractures and improvement of range of motion in the lower extremities
3. Reduction of pain associated with hypertonia
4. Maintenance of skin integrity/prevention of pressure ulcers
5. Decrease of frequency of urinary tract infections
6. Decrease in the frequency of digestive disorders
7. Improvement of bowel function.
8. Maintenance of bone density in adults when requested no later than 18 months from the onset of the condition that caused the loss of ability to walk or in children under age 21

The therapy program must require the following:

1. Adult members to stand at least 30 minutes per day at least five times per week
2. Children members to stand at least 7 – 10 hours per week
3. A child with a standing program at school must stand a total of at least 10 hours per week when adding the standing of his/her school program and home program together

The therapy program must be established by a therapist with experience working with standers.

Trial

A trial of the requested stander in the member’s home is required.

If the requested stander is replacing an existing stander of the same type (prone, supine, sit to stand), the trial need only establish the following:

1. The new stander fits in the member’s home
2. The new stander is configured to meet the member’s standing needs. This can usually be accomplished within a few hours.

If the member participated in a standing program at school, a day program, or previous residence and has lost access to the stander, the trial needs to establish the following:

1. The new stander fits in the member’s home
2. The new stander is configured to meet the member’s standing needs
3. The member is willing to use the stander in the new environment
4. Caregivers are willing and able to assist with the standing program (this can usually be accomplished within a few days)

If the member does not have a history of a standing program within the previous 12 months, the trial needs to establish the following:

1. The stander fits in the member’s home
2. The stander is configured to meet the member’s standing needs
3. The member is willing to use the stander
4. Caregivers are willing and able to assist with the standing program
5. The standing program has resulted in progress toward the stated goals or the member has significantly increased standing time (this can usually be accomplished within two weeks)
6. A log completed by the member or caregiver must be included in the authorization request

If the requested stander is replacing an existing stander but is of a different type (prone, supine, sit to stand), the trial needs to establish the following:

1. The stander fits in the member’s home
2. The stander is configured to meet the member’s standing needs
3. The member is willing to use the stander
4. Caregivers are willing and able to assist with the standing program
5. The standing program has resulted in progress toward the stated goals or the member significantly increased standing time (this can usually be accomplished within two weeks)
6. A log completed by the member of caregiver must be included in the authorization request

All authorization requests must include an assessment by the physical therapist (PT). The assessment must include the following:

1. The current program and functional goals
2. Baseline for each goal
3. The effect of the trial period or previous standing on the goals
4. A description of the member’s history of standing
5. Functional mobility status, including the amount of assistance required for sitting, standing, ambulation, and transfers
6. All authorization requests must include descriptions of what less costly alternatives were considered/tried, and why they were rejected. This should address other standing devices considered, as well as other approaches for meeting the member’s goals.
7. Authorization requests for members under age 21 must describe how the requested device will accommodate expected growth
8. Authorization requests for members with progressive diseases or conditions must include the following:
   1. An assessment of the effects of the disease’s progress on the member’s ability to use the requested device
   2. An estimate of how long the requested device is expected to meet the member’s needs

Accessories Purchase Criteria for Rented Standers

1. Member must have a diagnosis of an underlying medical condition that involves inability to walk
2. Rental of the stander for 2 – 3 months must be necessary for continuation of a school-based therapy program or for temporary use when there is a decline in functional mobility (e.g., following orthopedic surgery)

Non-Covered Services

A stander will not be purchased for a member with any of the following contraindications:

1. Inadequate bone density to safely allow standing
2. History of syncope
3. History of sudden changes in blood pressure
4. Uncontrolled dependent edema
5. Adverse reactions while standing during the trial period

A stander will not be purchased for a member who regularly uses a stander in a school or day program, although 2 – 3 months’ rental may be appropriate when school is not in session.

“Regularly” means a child who uses a stander 10 hours per week or an adult who uses a stander five times per week for 30 minutes or more each time.

A stander will not be purchased for a member who has a gait trainer.

Suction Pump (Respiratory)

Code: E0600

Authorization is not required.

A portable suction pump may be used as a stationary suction. PrimeWest Health will not cover both portable and stationary suction pumps unless documentation supports the need for both types.

Included with purchase/rental:

1. Battery
2. Battery charger
3. Carrying case
4. Overflow valve
5. Permanent collection bottles
6. Pump

Separately bill:

1. Connecting tubing
2. Disposable collection bottles
3. Suction catheters

When billing for both a portable and a stationary suction pump on the same date of service (DOS), bill both units on one line. Include in the description: medically necessary – 1 stationary/1 portable.

Topical Products Defined as Drugs

Skin care products classified as drugs and provided for members with catheters, ostomies, or other conditions may be covered only under the following circumstances:

1. The member has a valid Healthcare Common Procedure Coding System (HCPCS) code assigned to and it is eligible for reimbursement on the Minnesota Department of Human Services (DHS) fee schedule; or
2. If no HCPCS code exists, an appropriate provider may submit a claim using the 11-digit National Drug Codes (NDC). The provider will be reimbursed at the contracted pharmacy rate if the NDC is on the formulary. State law does not allow medical equipment and supply providers or home health care agencies to provide items that meet the definition of a drug.

The following items are defined as drugs and may be covered only as described above. This is not an inclusive list. Not all products that fit into one of the categories listed below are covered.

1. Urea solutions
2. Antifungal compounds
3. Antiseptics
4. Topical anesthetic and antipruritic solutions
5. Topical corticosteroids
6. Topical anti-infective agents and cleaners
7. Anti-psoriasis and anti-eczema medications
8. Aluminum chloride, fluorouracil, and hydroquinone solutions
9. Sterile saline or water (includes irrigation solutions labeled as Rx legend)
10. Aluminum acetate solution and lime sulfur dressing and soaks
11. Antibiotic-steroid combination
12. Zinc oxide compounds
13. Vitamin A & D ointments
14. Scabicides and pediculicides
15. Lactic acid lotion
16. Anti-acne medications
17. Burn anti-infective agents
18. Wart medications
19. Enzymes

Non-Topical Products

Lubricants for ostomy patients, non-legend sterile saline irrigation solutions, skin barriers, and other topical products that do not contain active ingredients and are not classified as drugs may be billed on the 837P professional claim with the appropriate HCPCS code. These items require a written order from the physician that includes the exact description of the product to be dispensed, the amount needed, and the length of time needed.

Transcutaneous Electrical Nerve Stimulator (TENS)

A transcutaneous electrical nerve stimulator (TENS) is a portable device that uses electrical current to decrease perception of pain. Electrodes placed on painful body parts send signals through electrical current to confuse a person’s pain receptors.

Eligible Prescribing Providers

1. Clinical Nurse Specialist
2. Nurse Midwife
3. Nurse Practitioner
4. Physician
5. Physician Assistant

Eligible Dispensing Providers

1. Federally Qualified Health Centers
2. Home Health Agencies
3. Hospitals
4. Indian Health Services
5. Medical Suppliers
6. Pharmacies
7. Rural Health Clinics

Covered Services

Codes: E0720, E0730, E0731, A4557, A4595

Acute Pain

• Covered for 60 days post-op
• Can be converted to longer term use if medical necessity persists after 60 days

Chronic Pain

• Available for purchase or rental
• Rental will be approved for 13 months, at which point it will become the member’s property
• Price will cap at the cost of the device

Only TENS units and conductive garments approved by the Food and Drug Administration (FDA) are covered.

One, two lead TENS supply is covered each month of use for members using a two-lead (E0720) TENS unit.

Two, two lead TENS supplies are covered each month of use for members using a four-lead (E0730) TENS unit. TENS supplies necessary for use of the TENS unit for one month include, but are not limited to, the following:

1. Adhesive
2. Adhesive remover
3. Batteries
4. Conductive paste or gel
5. Electrodes

Replacement lead wires are covered to a maximum of twice per year.

Suppliers must verify the TENS unit is still being used before dispensing TENS supplies/lead wires. A new order is not required unless the original order had an end date.

Non-Covered Services

TENS is not medically necessary for the treatment of chronic low back pain, defined as low back pain from any cause lasting six weeks or more.

Supplies other than listed above for use with the TENS unit are not covered.

If criteria are met, rental of a TENS unit is covered for members with acute pain. If criteria are met, purchase or rental of a TENS unit is covered for chronic pain other than chronic low back pain.

Authorization

Service Authorization may be required for the purchase or rental of TENS units. Service Authorization decisions are based on medical necessity. TENS units are not medically necessary for the treatment of chronic low back pain, defined as low back pain from any cause lasting six weeks or more. Please review the Service Authorization section for specific information regarding Service Authorizations.

Each month rental is one unit. If 2 months’ rental is needed, request two units.

For the authorization request, provide the following documentation:

1. For acute (non-malignant) post-operative or post-traumatic pain, TENS unit will be approved for rental for a period of no more than 60 days following surgery or injury.
   1. Submit a description of the member’s operation or trauma and the need for TENS. Date of the surgery or injury (should be less than 30 days)
   2. If a four-lead TENS unit is requested, document why two leads are not sufficient to meet the member’s needs.
   3. If the device is required for more than 60 days, the member must meet the criteria for chronic pain.
2. For chronic pain conditions that are refractory to other member-appropriate methods of treatment, TENS units will be approved for purchase or rental up to 13 months. After 13 months’ rental, the unit is the member’s property. Provide the following:
   1. Diagnosis and description of the pain and approximate date of onset of pain
   2. Description of prior therapies attempted and member’s response
   3. Documentation of any treatments considered but rejected as not appropriate for the member
   4. If a four-lead TENS unit is requested, document why two leads are not sufficient to meet the member’s needs.
   5. Include an estimate of duration of need. Each month rental is one unit. Request one unit for each month needed when requesting rental.
   6. Documentation of the member’s use, how often, and whether the TENS alleviates the pain
3. A form-fitting conductive garment may be medically necessary for use with a TENS unit for some members. PrimeWest Health will authorize the purchase of form fitting conductive garments for use with authorized TENS units if any of the following criteria are met:
   1. The area receiving stimulation is inaccessible to the member or caregiver with the use of conventional electrodes, tapes, and lead wires
   2. The area receiving stimulation is so large or the areas so numerous conventional electrodes, tapes, and lead wires are not practical
   3. The member has a skin condition or other medical condition that prevents the application of conventional electrodes, tapes, and lead wires
   4. Submit documentation addressing one or more of the criteria above. If requesting authorization because the area is inaccessible, include information about the availability of caregivers to assist the member.

Transfer and Mobility Device (TRAM)

Overview

A transfer and mobility device (TRAM) is used to ambulate, lift, or transfer a member. The gait training function of the device allows for safe ambulation. The sit-to-stand function permits a person to move from a seated position to a standing position. The sit-to-stand function also allows for passive standing. The seated transfer function is used to transfer a person from one surface to another.

Eligible Providers

Durable medical equipment vendors must be enrolled as PrimeWest Health medical equipment providers. Providers must be able to provide the following support services:

1. Delivery and setup
2. Repairs
3. Warranty service (a copy of the warranty must be given to the member and a copy kept in the provider’s records)
4. Education and ongoing assistance with the use of the TRAM

Providers must have skilled and knowledgeable service personnel to provide timely service and repairs.

TPL and Medicare

Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare in order to assist members for whom PrimeWest Health is not the primary payer.

PrimeWest Health quantity limits and thresholds apply to all members unless only Medicare co-insurance or deductible is requested.

Eligible Members

The TRAM is covered for eligible PrimeWest Health members who meet the coverage criteria.

Covered Services

Code: E1399 NU Transfer and Mobility Device (TRAM) (example includes the Rifton TRAM)

Coverage Criteria

Documentation must establish one of the following situations:

1. Member requires equipment for two or more TRAM functions, and does not currently have functional equipment. For example, member requires a gait trainer and seated transfer (lift).
2. Member requires only one TRAM function and the TRAM represents the least costly, medically appropriate way to meet the member’s medical needs.

Requests for Use as a Gait Trainer

The member must meet PrimeWest Health criteria for a gait trainer, including documentation of the following:

1. Member’s age, height, weight, and current level of mobility
2. A physical therapy evaluation with baseline measurements, functional goals, and recommendations for an assistive device to support gait training and ambulation, as well as any history of gait training and devices used
3. Body weight support is required
4. A specific therapy program detailing the frequency and duration of sessions during which the member will use the device
5. The member cannot be safely and effectively transferred into a less costly gait trainer using other equipment
6. Documentation of satisfactory caretaker use of the TRAM
7. The TRAM is documented as fitting in all necessary parts of the member’s home with a description of how it will be used in critical areas of the residence
8. Less costly alternatives considered and why they were rejected (include specific product information)

Requests for Use for Seated Transfer

Member must meet PrimeWest Health criteria for a transfer device, including documentation of the following:

1. Member weight and height
2. The member requires help from another person to transfer between a wheelchair, bed, commode, or other surfaces in the home
3. Description of the current method of transfer and why it does not meet the member’s needs
4. Documentation that a medical condition requires a seated transfer must include one or more of the following:
   1. Body weight support is required
   2. Transfer device in an upright sitting position is required due to respiratory complications
   3. The member cannot be safely and effectively transferred using other equipment
5. The plan of care
6. Documentation of satisfactory caretaker use of the TRAM
7. The TRAM is documented as fitting in all necessary parts of the member’s home with a description of how it will be used in critical areas of the residence
8. Less costly alternatives considered and why they were rejected (include specific product information)

Requests for Use for Sit-to-Stand Transfer and Passive Standing

Member must meet PrimeWest Health criteria for a stander (refer to Standers), including documentation of the following:

1. Have little or no potential for walking
2. Cannot stand unassisted for appreciable amounts of time
3. Justification for body weight support and weight bearing
4. A diagnosis of an underlying medical condition that involves inability to walk or loss of walking ability
5. The stander must be an integral part of a therapy program in the home with specific, measurable outcomes unique to the member
6. Satisfactory caretaker use of the TRAM
7. The TRAM is documented as fitting in all necessary parts of the member’s home with a description of how it will be used in critical areas of the residence
8. Less costly alternatives considered and why they were rejected (include specific product information)

Options and Accessories

The following items are included with the TRAM:

1. Base frame
2. One battery
3. Thigh straps (pair)
4. Charger power cord
5. One battery charger

Include a list of all additional accessories not included with the TRAM with documentation of medical necessity for each item added to the device.

Options and accessories for the TRAM may include the following:

1. Low-base option
2. Forearm supports
3. Arm platforms
4. Walking saddle
5. Swivel locks
6. Removable black belt

Authorization

Authorization is always required.

1. If the member is currently in a nursing facility, the medical review agent will consider authorization if requested as part of a discharge plan. All other criteria must be met.
2. Authorization requests for members under age 21 must describe how the requested device will accommodate expected growth.
3. Authorization requests for members with progressive diseases or conditions must include the following:
   1. An assessment of the effects of the disease’s progress on the member’s ability to use the requested device
   2. An estimate of how long the requested device is expected to meet the member’s needs
4. Submit a log or documentation of a home trial with the authorization request.
5. All authorization requests must include an assessment by a physical therapist. The assessment must include the following:
   1. The current program, functional goals, and baseline for each goal
   2. Functional mobility status, including the amount of assistance required for sitting, standing, ambulation, and transfers

Authorization is required for non-mobility equipment repairs or replacements when the cost of the parts and labor exceeds $1,000.

Submit authorization requests with required documentation to the authorization medical review agent.

Billing

Approved Purchase

Follow these billing guidelines for approved purchases:

1. Use MN–ITS 837P Professional
2. Submit a claim for the TRAM; make sure the HCPCS code, modifiers, and the description on the claim match the same information on the prior authorization
3. Enter the authorization number in the appropriate field of the claim.

Accessories for Previously Purchased Standers

If billing for accessories under $400, bill using A9999 and the NU modifier. Attach the manufacturer’s invoice and a price list or a quote from the manufacturer dated within three months. Clearly indicate each item that is being requested on the pricing documentation. Do not modify, alter, or change the pricing documentation.

If billing for accessories over $400, bill on a separate claim. Make sure the HCPCS code, modifiers, and description on the claim match the same information on the authorization. Enter the authorization number in the authorization field on the claim information table of MN–ITS.

Urological and Bowel Supplies

Catheters and related supplies are used to drain urine from the bladder or promote evacuation of the contents of the colon when members are unable to completely empty the bladder by voiding or unable to control their bowel movements.

Eligible Members

Catheters and related supplies are covered for eligible PrimeWest Health members unable to completely empty their bladder by voiding or unable to control their bowel movements.

Covered Services

Codes

A4310 – A4316 and A4354: insertion trays for indwelling catheters
A4338 – A4346: indwelling catheters without insertion trays
A4351 – A4353: intermittent catheters
A4357 – A4358, A5102, A5112: drainage collection systems
A4320 – A4334, A4349, A4355 – A4356: related supplies
A4335: Miscellaneous incontinence supplies
A4453: Rectal catheter, with or without a balloon
A4459: Anal irrigation system
A9900: Accessory unit for anal irrigation system

Indwelling Catheters/Insertion Trays

Most members can be served with one indwelling catheter per month. A second catheter may be required if the catheter is accidentally removed, malfunctions, or becomes obstructed or if the member has a medical history that requires the catheter to be replaced more than once per month. One insertion tray is covered per episode of indwelling catheter insertion. An insertion tray is not covered for use with an intermittent catheter. Documentation must support the quantity dispensed. Documentation of medical necessity (e.g., recurrent encrustation, inability to pass a straight catheter, or sensitivity to latex) is required for a specialty indwelling catheter (A4340) or a silicone catheter (A4312, A4315, A4344).

Intermittent Catheterization

Most members can be served with 150 – 180 intermittent catheters per month. Additional intermittent catheters may be required if the member has a medical history that requires more than six episodes of catheterization daily. Intermittent catheters with sterile insertion supplies are covered if the member has a medical history that requires sterile, rather than clean, catheterization and documentation of medical necessity for sterile catheterization is maintained in the medical supplier’s files. Documentation must support the quantity dispensed.

Drainage Collection Devices

Most members can be served with 1 – 2 drainage bags/bottles per month. Additional drainage bags/bottles may be required if the member has a medical history that requires the bag to be replaced more frequently. Documentation must support the quantity dispensed.

Irrigation Supplies

Most members who require intermittent irrigation can be served with one irrigation tray/syringe per week. Up to 31 irrigation syringes/trays may be required if the member has a medical condition that requires daily irrigation with a new syringe. Documentation must support the quantity dispensed. Supplies for intermittent irrigation of an indwelling catheter include either an irrigation tray or an irrigation syringe, and sterile water/saline.

Most members who require continuous irrigation can be served with one irrigation tubing set per day for up to two weeks. Up to 31 continuous days may be required if the member has persistent obstructions. Supplies for continuous irrigation include a three-way Foley catheter, irrigation tubing set, and sterile water/saline.

Anal Irrigation System and Accessory Unit

Anal irrigation is used for fecal incontinence, chronic constipation, or time-consuming bowel management procedures when other conservative bowel management alternatives have been tried and failed.

The member must meet one of the following criteria:

1. Have fecal incontinence
2. Have chronic constipation
3. Require bowel management methods or a combination of methods requiring more than 30 minutes a day

The following first-line bowel management methods have been prescribed and demonstrated as failures:

1. Dietary modification
2. Medication
3. Enema bag
4. Physical therapies (pelvic floor stimulation, biofeedback, electrical stimulation)

Most members can be served with two anal irrigation systems per year (A4459); however, up to four per year are allowed (one per dispensing). 

Rectal catheters (A4453) are considered accessory units and are separately payable using A4459 (1 unit = 1 catheter). PrimeWest Health covers up to 31 catheters per month if the member requires daily catheter use.

Authorization

PrimeWest Health does not currently require authorization for urological supplies. Identified excessive use will be investigated. Providers are required to maintain documentation to support quantity dispensed.

Authorization is always required for codes A4453, A4459 and A9900. Include documentation of demonstrated failure and length of trial for first-line bowel management methods. 

Billing

1. If the member has Medicare, PrimeWest Health will pay the deductible/co-insurance on any units for which Medicare has made payment. Any units that Medicare denies payment for must meet PrimeWest Health’s quantity and authorization requirements. Authorization can be requested retroactively.
2. Only products that have undergone coding verification review by the Medicare Pricing, Data Analysis, and Coding (PDAC) contractor may be billed with A4326. Include the name of the product in the notes field.

Ventilators

Ventilators are used to move air in and out of the lungs.

Because ventilators are life-sustaining equipment, providers must do the following:

1. Conduct an in-home environmental assessment to confirm the patient’s residence will safely sustain the ventilator and auxiliary equipment, along with routine household appliances and activities. The assessment includes, but is not limited to, checking for grounded electrical outlets and functional smoke detectors, emergency protection planning, and escape route planning.
2. Train the member and caregivers in proper use of the ventilator, including infection control, alternative ventilation, and emergency ventilation procedures
3. Have 24-hour/day support for troubleshooting and ventilator exchange due to unresolved malfunction
4. Ensure critical alarms are appropriately set on the ventilator
5. Ensure a backup alarm system is in place for when the patient is not directly observed by a fully trained caregiver
6. Perform periodic maintenance at least as frequently as recommended by the manufacturer

Covered Services

Codes: E0465, E0466, E0467, E0468

Ventilators are covered for members who have been determined by a physician to need a ventilator.

Both a portable and a stationary ventilator may be covered when documentation in the medical supplier’s files establishes that a portable ventilator alone does not meet the member’s needs. If two different types of ventilators are medically necessary (for example, a positive pressure ventilator and a negative pressure ventilator), both types can be covered. Rental of the multi-function ventilator (E0467) is covered for members who would otherwise require both a portable and a stationary ventilator, but can be served by the multi-function ventilator alone. E0467 must be billed without another ventilator rental. In addition, the multi-function ventilator also has the capability of completing the nebulizer, oxygen, cough assist, and suction functions. All codes encompassed by E0467 are not separately reimbursable unless the member has oxygen needs over 6 liters per minute.

Non-Covered Services

• Backup devices, other than two ventilators with authorization, are not covered as they are a duplication of equipment.
• The following supplies for ventilators, as ventilator rentals do not convert to purchase, and therefore supplies are included in payment for the service:
  • Batteries (A4611)
  • Cables (A4612)
  • Chargers (A4613)

Authorization

Authorization is always required.

Billing

1. When dispensing a medically necessary pressure support ventilator, bill using modifiers RR and U3. Providers must have documentation from the prescriber that establishes the need for pressure support. When dispensing other accessories or devices, which have been coded by the PDAC, providers must bill with the assigned procedure code and accept the MHCP fee schedule rate.
2. Ventilators have been determined by the Centers for Medicare & Medicaid Services (CMS) to require frequent and substantial servicing. PrimeWest Health will not purchase ventilators, and rented ventilators do not convert to purchase.

Included with initial rental dispensing:

1. Battery
2. Carrying case
3. Cart
4. Electric cord
5. Exhaustion valves
6. High/low/disconnect alarms
7. High pressure hoses
8. Intermittent Mandatory Ventilation (IMV) devices
9. Positive End-Expiratory Pressure (PEEP) valve
10. Pressure manometers
11. Spirometer, any kind
12. Stand
13. Water traps

Separately billable:

1. Breathing circuits
2. Humidifier
3. Manual resuscitation bags
4. Oxygen
5. Oxygen analyzers

Wigs

Code: A9282

Authorization is not required for contracted providers.

Criteria: Covered only for treatment of medical conditions that result in hair loss. PrimeWest Health will cover one wig per 366-day period (one year plus one day).

 

PW_11-19_537
Updated_05/26/2026