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

All temporary Durable Medical Equipment (DME) policy flexibilities outlined in COVID-19 Special Bulletins remain in effect as of this publication date. See COVID-19 Special Bulletins for details.

An amended version of Clinical Coverage Policy 5A-3, Nursing Equipment and Supplies with an effective date of Oct. 1, 2020, was posted to the NC Medicaid Clinical Coverage Policy web page. Following is a summary of updates:

In Subsection 5.3.3, Standard Blood Glucose Monitors, Continuous Glucose Monitors and Related Supplies, the prior authorization (PA) requirement for blood glucose monitors with an integrated voice synthesizer was removed. For continuous glucose monitor (CGM) systems, the medical necessity criteria were updated, the PA requirement was removed and coverage was expanded to include all ages. Also, language was added to indicate that effective July 1, 2020, therapeutic CGM systems would be covered under the pharmacy benefit while non-therapeutic CGM systems would remain covered under the DME benefit.

In Subsection 5.3.7, Automatic External Defibrillator, With Integrated Electrocardiogram Analysis, Garment Type, the criterion requiring users of wearable cardioverter defibrillators (WCDs) to be 18 years of age or older was removed and the following note was added:

• Note: The beneficiary must meet the Food and Drug Administration (FDA) and manufacturer’s requirements for the specific device prescribed, including but not limited to age, weight and chest circumference.

Additionally, the PA language for WCDs was clarified to indicate that the initial prior authorization is for three months. And the prescriber for WCDs was changed from “cardiologist” to “physician.” 

In Subsection 5.3.9 Miscellaneous Durable Medical Equipment and Medical Supplies, the following medical necessity criteria, without PA, were added for automatic blood pressure monitors and floor scales:

• Automatic blood pressure (BP) monitors may be considered medically necessary for beneficiaries who are required by their medical provider to independently monitor and report their blood pressure from home due to conditions such as hypertension, hypotension, renal failure, or complications of pregnancy.
• A floor scale, regular capacity or extra capacity, may be considered medically necessary for beneficiaries who are required by their medical provider to independently monitor and report their body weight from home due to conditions such as heart failure, renal failure, or complications of pregnancy. 

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

• The 18-year old age limit was removed from HCPCS codes K0606 (automatic external defibrillator, with integrated electrocardiogram analysis, garment type).
• The monthly quantity limits for HCPCS code A4244 (alcohol or peroxide, per pint) was corrected from “100 per month” to “4 pints per month;” HCPCS code A4252 (blood ketone test or reagent strip, each) was corrected from “100 per calendar month” to “100 test strips per calendar month;” HCPCS code A9999 (miscellaneous DME supply or accessory, not otherwise specified (for use with Farrell Valve only)) was corrected from “1 per day” to “31 per month;” HCPCS code A4217 (sterile water/saline, 500 ml) was updated to 100 per month; and HCPCS code A4456 (adhesive remover, wipes, any type, each) was corrected from “1 box of 50 per month” to “50 wipes per month.”
• Coverage was added for HCPCS codes A4670 (automatic blood pressure monitor) and E1639 (scale, each), with lifetime expectancies of three years each.

In the DME fee schedule, the asterisk indicating an item requires PA was removed from HCPCS codes:

Additional Resources

The DME fee schedule and full text of Clinical Coverage Policy 5A-3, Nursing Equipment and Supplies is available at North Carolina Medicaid’s Durable Medical Equipment web page. All COVID-19 Special Bulletins are available here.

Contact

NC Medicaid Contact Center, 888-245-0179