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Coverage criteria policies

Equipment in skilled nursing / long term care facility – Minnesota Health Care Programs

These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Items that appear on the HealthPartners Prior Approval list will also require prior approval if ordered when the member is in a skilled nursing facility or long term care facility.

For coverage of individual items, please see related content at the right for link to Medical Supplies and Equipment Benefit Code Guide.

Note: Prior authorization requirements on this list are only applicable to HealthPartners members if HealthPartners has is a unique policy. Please check the unique HealthPartners policy to determine prior approval requirements.

Coverage

Equipment in an LTC/SNF/NF or LTC is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

  1. The term, “Durable Medical Equipment” (DME) does not include Prosthetics or Orthotics. Refer to the individual coverage policy for Orthotics or Prostheses.
  2. Ancillary DME / supplies may be eligible for rental or purchase. These include, but are not limited to life support ventilators, CPAP, BiPAP, oxygen system, seating support systems, TENS, NMES, electrodes, slings, negative pressure wound therapy pump (Wound VAC) (E2402), etc.
  3. Wheelchairs in SNF/NF/LTC:
    1. Obtain authorization for all wheelchairs. If the wheelchair is approved for payment outside the facility per diem, the wheelchair becomes the property of the resident, not the facility.
    2. Document the resident’s planned discharge date to the community. Approval of payment outside of the SNF/NF/LTC facility per diem will be considered when:
      1. A resident needs a wheelchair that must be modified. ” Modified” means the addition of an item to the wheelchair that cannot be removed without damaging the equipment, or that permanently alters the equipment, and once altered the chair could not be used by any other resident.
        AND
      2. A wheelchair (including a power wheelchair) must be necessary for the continuous care and exclusive use of a resident due to an unusual medical need. Exclusive use alone does not justify separate payment if the chair required is a stock chair. The resident must also have a medical need that is unusual for the population of the facility.
        AND
      3. The medical professionals working with the resident document the extent to which it is medically necessary to provide a modified wheelchair. Send this documentation with the authorization form. Wheelchairs manufactured in various widths and sizes for larger individuals are not considered modified wheelchairs.
    3. Standard wheelchairs in a SNF/NF/LTC Facility
      Standard wheelchairs in an SNF/NF/LTC are included in the SNF/LF/LTC facility per diem.
      Standard wheelchairs with customized features (e.g., Tilt 'n’ Space) will be reviewed for medical necessity.
    4. Custom wheelchairs in an SNF/NF/LTC Facility
      Wheelchairs that must be modified for a member, and are used exclusively and continuously by the member, will be reviewed for medical necessity.
      Customized wheelchairs with standard additions may be approved for purchase outside a facility’s per diem, but non-customized items requested with the wheelchair will continue to be included in the facility’s per diem payment.
    5. Repair of Member-Owned Wheelchair in an LTC Facility
      Repairs are covered for member-owned wheelchairs that are medically necessary when residing in an SNF/NF/LTC if the chair would be reimbursable outside of a facility per diem. No prior authorization is necessary,
    6. Custom Molded Wheelchair Seating Systems (E2609, E2617) are covered if medically necessary. No prior authorization is required.
      For other wheelchair seating system codes, please see related content at the right for link to Medical Supplies & Equipment Benefit Code Guide. No prior authorization is required.
    7. E2609: Seat module molded to fit a member (orthotic seating system, custom fabricated for attachment to wheelchair base).
    8. E2609 and E2617: Seat and back sections molded as one piece (orthotic seating system, combine back module and seat module custom fabricated for attachment to wheelchair base).
    9. Prefabricated Custom Seating Systems for Wheelchairs (E2605-E2608, E2613-E2616, E2620, E2621, and K0669)
      When billing a head support attached to the prefabricated seating system use code K0108. Do not use the codes for wheelchair head rests. Payment for a head support includes mounting hardware.

Indications that are not covered

  1. Routine DME / supplies including but not limited to: wheelchairs, walkers, hospital beds, canes, commodes, traction equipment, formula, suction machines, patient lifts, commodes, weight scales, etc. Examples of supplies include but are not limited to ostomy supplies, enteral feeding supplies, formula, wheelchair cushions, urinary catheters & supplies, wound care / dressing supplies (A6010-A6457) etc.
  2. Certain equipment and supplies used for prevention and treatment of skin pressure areas and decubiti for members living in SNF/NF/LTC. These items are included in the facility per diem. The following items and HCPCS codes will not be covered for members living in a SNF/NF/LTC:1
    1. Group 1 pressure reducing support surfaces; (A4640, E0181-E0189, E0196-E0199)
    2. Group 2 pressure reducing support surfaces; (E0193, E0277, E0371, E0372,E0373)
    3. Group 3 pressure reducing support surfaces; (E0194)
    4. 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.

Definitions

Assisted Living Facilities and Board and Care Facilities are not considered SNF or LTCs. Equipment needs for these members are outside the scope of this policy. Standard DME policies apply.

Skilled Nursing Facility (SNF) - a facility that is certified by Medicare to provide inpatient skilled nursing care, rehabilitation services or other related health services. Such services can only be performed by, or under the supervision of, licensed nursing personnel. 3

Nursing Facility (NF) - a long term care facility (LTC) certified by the Minnesota Department of Health for services provided and reimbursed under Medicaid. Also known as Nursing Home or long term care.3

Routine DME / Supplies are expected to be available and supplied by the SNF/NF/LTC. Including but not limited to: wheelchairs, walkers, hospital beds, canes, commodes, traction equipment, formula, suction machines, patient lifts, commodes, weight scales, etc. Examples of supplies include but are not limited to ostomy supplies, enteral feeding supplies, formula, wheelchair cushions, urinary catheters & supplies, wound care / dressing supplies (A6010-A6457) etc.

Ancillary DME / Supplies are tailored exclusively to an individual’s specific medical needs and are ordered under the direction of a physician. These items are more complex medical equipment and may be considered for coverage under the DME benefit. Items include, but are not limited to: life support ventilators, CPAP, BIPAP, oxygen system, seating support systems, TENS, NMES, electrodes, slings, negative pressure wound therapy pump (Wound VAC) (E2402), etc.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

Items must be received from a contracted vendor for in-network benefits to apply.

Portions of this policy were taken from the MHCP Manual:

  1. MHCP Provider Update- Equipment and Supplies – Pressure Reducing Support Surfaces Revised 1-29-2013.
  2. Medical Supply Coverage Guide
  3. MHCP Provider Manual -: Equipment & Supplies (Chapter 23)
  4. 2016 Minnesota Senior Health Options MSHO Model Contract

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Policy activity

  • 03/01/1998 - Date of origin
  • 03/01/1998 - Effective date
Review date
  • 02/2017

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