Updates to Clinical Coverage Policy 5A-3, Nursing Equipment and Supplies

On Oct. 1, 2019, an amended version of Clinical Coverage Policy 5A-3, Nursing Equipment and Supplies, was posted to the North Carolina Medicaid website. In addition to correcting numbering, grammatical and style errors, the following changes have been made:

In Subsection 1.2, Categories of Durable Medical Equipment and Medical Supplies, the reference in the last paragraph to submitting prior authorization (PA) requests for unlisted durable medical equipment (DME) and medical supplies for NC Medicaid beneficiaries over 21 years of age “directly to the Division of Medical Assistance (DMA)” was updated to reflect the current practice of submitting them electronically through NCTracks like all other DME PA requests. This practice became effective Oct. 28, 2018 and was communicated in the Sept. 27, 2018 NCTracks Newsletter.

In Subsection 5.3.2, External Insulin Infusion Pump, references to the requirement for the DME provider to supply documentation from the manufacturer that a non-functional pump was not repairable, and the warranty had expired when submitting for PA review for a replacement pump, was updated to accept this documentation from the DME provider instead.

In Subsection 5.3.3, Standard Blood Glucose Monitors, Continuous Glucose Monitors and Related Supplies, language was updated for clarity, and physician assistants and nurse practitioners were added as allowable treating practitioners.

Additionally, this Note was added:

• Note: Standard BGMs and preferred brand BGM supplies do not require prior authorization. However, prior authorization is required for non-preferred brand BGM supplies. For the National Drug Codes (NDCs) of preferred brand BGM supplies, refer to the DME fee schedule on the NC Medicaid website.

In Subsection 5.3.6, Nutrition, the requirement for an Oral Nutrition Product Request Form be submitted with PA requests for oral nutrition products was eliminated.

In Subsection 5.3.8, Incontinence, Ostomy, and Urinary Catheter Supplies, the following Note was added to clarify medical necessity and PA requirements for pre-moistened incontinence wipes:

• Note: Pre-moistened incontinence wipes must not be billed using A4335 or any other HCPCS code without prior authorization based on EPSDT guidelines or, for beneficiaries over age 21, the procedure outlined in Attachment D: Requesting Unlisted DME and Medical Supplies for Adults. NC Medicaid’s Program Integrity Unit and its authorized agents continue to monitor DME provider billing of A4335 for pre-moistened incontinence wipes to ensure compliance with this policy. Any future review revealing non-compliance with Medicaid regulation, rule, and policy may be subject to recoupment.

In Subsection 5.3.9, Miscellaneous Durable Medical Equipment and Medical Supplies, the medical necessity criteria for sterile and non-sterile gloves was updated to read:

• Sterile and non-sterile gloves may be considered medically necessary when used with covered Durable Medical Equipment and Supplies by the beneficiary or to protect the beneficiary from infection. Gloves used by an outside agency for the caregiver’s protection, are considered the agency’s overhead cost and must not be billed to Medicaid.

In Subsection 5.5, Durable Medical Equipment and Medical Supplies Limitations, the instructions for submitting a PA request to override a quantity limit or lifetime expectancy was updated to read:

• A PA request for an override of a quantity limit, or lifetime expectancy must contain the usual PA documentation (Subsections 5.2 and 5.3) along with the following additional information:
  • The item being requested for an override clearly marked on the CMN/PA form.
  • The type of override (quantity limit, or lifetime expectancy) clearly stated.
  • An explanation of the medical necessity for the override from the physician, physician assistant, nurse practitioner, or therapist.Override PA requests are reviewed for medical necessity as per usual PA review timelines.

    Override PA review outcomes are communicated to providers and beneficiaries in the same way as a typical PA request.

In Subsection 5.9, Replacing Medical Equipment, criterion d. was added:

• d. In cases of wide-spread natural disasters, documentation is accepted from any of the entities listed above or from the NC Division of Emergency Management, Federal Emergency Management Agency, American Red Cross, the National Guard or other appropriate state or local authorities and agencies on the ground in the affected areas.

In Subsection 6.4, Accepting Payment, language was added to remind providers billing Medicaid beneficiaries that they must comply with North Carolina Administrative Code 10A NCAC 22J .0106.

In Attachment A: Claims-Related Information, Section C: Code(s), the following updates were made:

HCPCS codes E0776 (IV pole), and A4435 (ostomy pouch, drainable, high output) were added back to the code list as they were inadvertently left out during a previous update.

Lifetime expectancies for HCPCS codes A9277 (transmitter; external, for use with interstitial continuous glucose monitoring system) and A9278 (receiver (monitor); external, for use with interstitial continuous glucose monitoring system) were updated to read: “Per manufacturer’s warranty”.

The monthly allowable quantity for A9276 (sensor; invasive (e.g. subcutaneous), disposable, for use with interstitial continuous glucose monitoring system, one unit = 1-day supply) was changed from a 30-day supply to 31-day supply per calendar month.

Quantity limits were added for HCPCS codes A4927 (gloves, non-sterile, per 100), and for A4930 (gloves, sterile, per pair) of 4 boxes/month and 75 pairs/month respectively. Quantities exceeding these limits must be submitted for prior authorization.

Coverage was added for HCPCS code A7048 (vacuum drainage collection unit and tubing kit).

Quantity limits for HCPCS codes T4543 (disposable incontinence product, brief/diaper, bariatric, each) and T4544 (adult sized disposable incontinence product, protective underwear/pull-on, above extra-large, each) were corrected to 192 per month and 200 per month respectively.

Attachment C: Oral Nutrition Product Request Form, became outdated and was deleted.

Attachment E: Requesting Unlisted DME and Medical Supplies for Adults, was re-lettered to Attachment D, and the following updates were made:

• Criterion b. was updated to instruct providers to submit PA requests through NCTracks instead of directly to NC Medicaid clinical policy.
• Criterion c. was updated to read: Providers may request non-covered, unlisted or restricted items using their identifiable HCPCS code (e.g.: E1012). If no HCPCS code exists, providers may use the miscellaneous combination K0108/W4005 for wheelchair accessories only, and for non-wheelchair items, the miscellaneous combination E1399/W4047.
• Criterion e. was updated to read: Providers should expect medical necessity reviews using this procedure to be longer than usual.
• Criterion f. was updated to read: Claims for items approved using this procedure should also be submitted through NCTracks.

Additional Resources

The full text of Clinical Coverage Policy 5A-3 is available at NC Medicaid’s Durable Medical Equipment (DME) web page.