Sec. 10.09.12.05. Limitations

The Program does not cover:

A. Incontinency pants and disposable underpads unless the following conditions are met:

(1) The incontinence supplies are medically necessary for medical conditions associated with prolonged urinary or bowel incontinence;

(2) For pull-on underwear type garments, the recipient is capable of independently putting on and removing the garment; and

(3) Disposable incontinence supplies meet, at a minimum, the following absorbent capacity standards:

(a) For children's diapers and underwear, not less than 800cc;

(b) For youth diapers and underwear, not less than 1,000cc;

(c) For small adult diapers and underwear, not less than 1,200cc;

(d) For medium adult diapers and underwear, not less than 1,750cc;

(e) For large, extra large, and bariatric adult diapers and underwear, not less than 2,000cc; and

(f) For disposable underpads, not less than 1,000 cc;

B. Osteogenesis stimulators unless the following criteria are met:

(1) The use is for noninvasive therapy;

(2) The bone fracture is at least 6 months old, except when used for pseudarthrosis; and

(3) The space gap of the fracture measures 1/2 centimeter or less, except when used for pseudarthrosis;

C. Osteogenesis stimulators beyond the first 6 weeks of use unless evaluations at the 6-week and 3-month intervals after initial date of service verify recipient use of at least 50 percent of the time prescribed, on a form designated by the Program;

D. The following durable medical equipment:

(1) Equipment prescribed primarily to provide comfort or convenience, including, but not limited to, emesis basins, posture support chairs, over-the-bed tables;

(2) Self-help devices including, but not limited to, grab bars, shower stools, and commode seats;

(3) Abdominal supports;

(4) Bed boards;

(5) Enema bags;

(6) Environmental controls;

(7) Exercise equipment and devices, unless home use of such equipment is a necessary component of an active physical therapy program;

(8) Geriatric chairs;

(9) Heating pads or lamps;

(10) Hot water bottles;

(11) Hydrocollators;

(12) Ice bags;

(13) Knee cages;

(14) Nasal atomizers;

(15) Restraints;

(16) Sitz baths;

(17) Soft collars;

(18) Whirlpools;

(19) Whirlpool bath equipment;

E. Disposable medical supplies and durable medical equipment provided in a facility or by a group when reimbursement is covered by another segment of the Program;

F. Items which are investigational or experimental in nature;

G. Nutritional supplements supplied by a DMS/DME provider under this chapter if the provider is also a licensed pharmacy and has a Medicaid Pharmacy provider number;

H. Food supplements or infant formulas, including enteral nutritional products and supplemental vitamin and mineral products, when administered orally;

I. Purchase of used equipment, except as approved by the Department as per Regulation .07L of this chapter;

J. Equipment if the recipient owns or otherwise has access to useable equipment that serves the same purpose as the requested equipment;

K. Replacement of equipment while the item is still under warranty or before having met the Department's life expectancy schedule unless prepayment authorization has been obtained;

L. Rental of any equipment not in good working condition for the entire length of rental;

M. Rental of equipment for any period longer than 90 days without renewed documentation of continued medical need from the prescriber for each 90-day period;

N. Modifications to motor vehicles;

O. Disposable medical supplies and durable medical equipment ordered by an individual who is not enrolled as a provider in the Program on the date of service; and

P. Disposable medical supplies and durable medical equipment ordered by an entity, facility, or other provider that is not an individual.