An amended version of Clinical Coverage Policy 5A-3, Nursing Equipment and Supplies with an effective date of Dec. 1, 2023, was posted to the NC Medicaid Clinical Coverage Policy web page. This applies to NC Medicaid Direct and NC Medicaid Managed Care.
Summary of Updates
- In Subsections 5.3.4 Phototherapy, 5.7.2 Monitoring Enteral Nutrition (EN) and 6.1 Provider Qualifications, language has been updated for clarity.
- In Subsections 5.3.11 Miscellaneous Durable Medical Equipment and Medical Supplies, the
following medical necessity criteria was added for a replacement blood pressure cuffs:- A replacement BP cuff may be covered if the cuff attached to an automatic blood pressure monitor becomes damaged or is no longer size appropriate.
- If these criteria are met, then prior authorization is not required for replacement blood pressure cuffs.
- In Attachment A: Claims-Related Information, Section C: Procedure Code(s), the following updates were made:
- Lifetime expectancy or quantity limitations were added for the following HCPCS codes:
| HCPCS code | Description | Lifetime Expectancy or Quantity Limitation |
|---|---|---|
| A4221 | Supplies for maintenance of noninsulin drug infusion catheter, per week (list drugs separately) | 1 per week |
| A2222 | Infusion supplies for external drug infusion pump, per cassette or bag (list dugs separately) | 16 per month |
| A4224 | Supplies for maintenance of insulin infusion catheter, per week | 1 per week |
| A4225 | Supplies for external insulin infusion pump, syringe type cartridge, sterile, each | 16 per month |
| A4663 | Blood pressure cuff only | 3 years |
Additional Resources
The durable medical equipment (DME) fee schedule and full text of Clinical Coverage Policy 5A-3, Nursing Equipment and Supplies is available at NC Medicaid’s Durable Medical Equipment web page.
Contact
NC Medicaid Contact Center, 888-245-0179