Durable Medical Equipment Providers

Service Authorization Required: Yes
CMN Required: SFN 528

Effective: March 2007
Revised: December 2022

Indications and limitations of coverage and medical appropriateness: 

At least one of the following conditions must be present for coverage of rental up to 6 months:

• Infant has significant apnea of 20 seconds or longer, or 
• Infant has mild to moderate apnea and desaturates below 90%, or
• Infant has periodic breathing with desaturation below 90%. 

Continued Coverage:

For coverage after the initial six-month period, additional month’s coverage must be prior authorized by the Department and the following conditions must exist and be documented by the physician/practitioner.

• Physician/practitioner documentation must include: 

a. Number of apnea episodes during the previous two-month period of use; and 
b. Infant continues to have significant alarms. (Log must be kept on file.); and  
c. Unresolved symptomatic apnea; and  
d. Tests and results of tests performed during the previous two-month period of use; and 
e. Estimated additional length of time monitor would be needed; and 
f.  Any additional pertinent information the physician may wish to provide. 

Documentation Requirements: 

• A prescription from ordering physician/practitioner.
• Physician/practitioner exam within 90 days of the service authorization start date.
• Physician/practitioner’s documentation needs to address criteria for use of apnea monitor including the projected length of time equipment will be needed.
• CMN 528. 

Non-covered:

According to the American Academy of Pediatrics, home apnea monitoring is not recommended in infants with siblings that were victims of sudden infant death syndrome (SIDS) and monitors used in these situations are not covered. Home apnea monitoring has not been proven to prevent sudden unexpected deaths in infants.

Date Revised: January 2017

Removed coverage criteria for apnea monitor requests for infants with siblings that were victims of sudden infant death syndrome (SIDS) and monitors and added non coverage rationale.  Reviewed and revised.  

Reviewed and made the following revisions. 

1. Added Continued Coverage section and the following:

• For coverage after the initial six-month period, additional month’s coverage must be prior authorized by the Department and the following conditions must exist and be documented by the practitioner.
• Practitioner documentation must include:
• Number of apnea episodes during the previous two-month period of use; and
• Infant continues to have significant alarms. (Log must be kept on file.); and
• Unresolved symptomatic apnea; and
• Tests and results of tests performed during the previous two-month period of use; and
• Estimated additional length of time monitor would be needed; and
• Any additional pertinent information the practitioner may wish to provide.

2. Added new department logo.

3. Removed for coverage after the initial six-month period, additional month’s coverage must be prior authorized by the Department and the following conditions must exist and be documented by the physician: infant continues to have significant alarms. (Log must be kept on file.) and unresolved symptomatic apnea. 

Date Revised: June 11, 2020

4.  Added to the Documentation Requirement section:

• A prescription from ordering physician/practitioner.
• Physician/practitioner exam within 90 days of the service authorization start date.

Date Revised: Dec. 27, 2022

Reviewed and reformatted. Added new logo.   

Date Revised:  June 23, 2023

Reformatted on HHS website.

Service Authorization Required: Yes
CMN Required: No

Effective Date:  May 2017
Revised Date: December 2022

Automatic External Defibrillator (AED), also known as Wearable Cardioverter Defibrillator (WCD) 

A wearable cardioverter defibrillator (WCD) is an external device (vest-like garment) that contains the following components:

• cardiac monitor;
• electrodes; alarm system; and
• cardioverter-defibrillator. 

The WCD monitors cardiac (heart) rhythm and delivers an electrical shock if a life threatening ventricular arrhythmia is detected. The WCD is worn continuously, 24 hours per day. 

Indications and limitations of coverage and medical appropriateness:

• A documented episode of ventricular fibrillation or sustained run of ventricular tachycardia lasting 30 seconds or longer. These dysrhythmias may either be spontaneous or induced during an electrophysiologic (EP)study, but may not be due to a transient or reversible cause and not occurring during the first 48 hours of an acute myocardial infarction;
• Familial or inherited conditions with a high risk of life-threatening ventricular tachyarrhthymia’s such as long QT syndrome, hypertrophic cardiomyopathy;
• Either a documented prior myocardial infarction or a dilated cardiomyopathy and measured left ventricular ejection fraction less than or equal to 35%;
• Documentation of a previously implanted defibrillator that due to infection, injury or illness requires a waiting period before ICD reinsertion;
• Documentation of an infection or other temporary medical condition that prevents the initial implantation of an ICD.
• WCD is for rental only and prior approval is given for a maximum time period of three months when the member meets all medical necessity and coverage criteria.  

Documentation Requirements:

• A prescription from prescribing physician/practitioner.
• Medical documentation supporting the need.
• Physician/practitioner exam within 90 days of the service authorization start date.  

Non-covered:

The FDA has not approved use of the WCD for the indications listed below. Therefore, the WCD is not medically necessary and not covered for a member who meets any one of the following:

• Meets the criteria for an ICD or already has an ICD implanted and operating;
• Is under 18 years of age;
• Has a vision or hearing problem that may interfere with reading or hearing the WCD messages;
• Is taking medication that would interfere with pushing the response buttons on the WCD alarm module;
• Is unwilling or unable to wear the device continuously, except when bathing or showering;
• Is pregnant or breast feeding; • Is of childbearing age and not attempting to prevent pregnancy; or
• Is exposed to excessive electromagnetic interference (EMI) from machinery, such as powerful electric motors, radio transmitters, power lines or electronic security scanners, EMI can prevent the WCD from detecting an abnormal heart rhythm.

Date Revised:  May 2017 

Established criteria as listed in policy

Date Revised:  January 3, 2020

Reviewed. Added new Department logo and changed 60 days to 90 days. 

Date Revised:  December 22, 2022

Updated with new logo 

Date Revised:  June 26, 2023

Reformatted on HHS website.

Service Authorization Required: Yes
CMN Required: None

Effective Date:  July 1, 2011
Revised Date: November 2022

A bath/shower chair sits in the bathtub or shower for bathing in the seated position. A tub transfer bench goes across the side of the tub and allows a member to safely slide into the tub and sit for bathing. 

Specialty bath/shower chairs are covered when a member requires postural support and stability while bathing. The frame is adjustable to provide tilt and recline to meet various positioning needs. 

Indications for coverage of the tilt/recline feature: 

Limited to one every five years. 

All of the following criteria must be met: 

• Unable to get in/out of the bath/shower independently and is unable to sit or stand in the bath/shower independently.
• Home assessment determines that bath/shower access is possible for the requested equipment; or
• Home assessment determines that once the equipment is in the bath/shower enclosure caregiver access to the member is adequate.

All accessories for the specialty chair require medical justification and must be included in the medical information provided. 

Accessories/items with the miscellaneous code E1399 require service authorization and a manufacturer invoice reflecting the acquisition cost on the requesting service authorization. 

Other accessories such as bath chair lateral supports, chest or pelvic straps, or wedge and pommel cushions are medically necessary when a member requires additional support to maintain the head or trunk in proper alignment or to maintain the member safely on the bath chair while bathing. 

Indications for coverage of the tilt/recline feature: 

• A tilt/recline shower chair is a shower chair that can be tilted or reclined to various angles, provides extensive support, and can be rolled into a shower for bathing. Prior approval is required. A tilt/recline shower chair is considered medically necessary when a member meets any one of the following criteria:
• Has extensive weakness, contractures, or abnormal tone requiring full body support; or
• Requires total assistance for transfers and bathing; or
• Has a medical need that requires the tilted or reclined position when upright; or
• Requires pressure relief at all times when sitting.

Indications for coverage of a non-standard seating system: 

• Current decubitus that is a stage 3 or 4; and
• Shower/commode chair needed for a minimum of 30 minutes or longer; or
• No decubitus and use of the shower/commode chair for a minimum of 2 hours or longer per toileting session.

Indications for coverage of foot plates: 

• No functional use of the lower limbs.

Indications for coverage of elevating leg rests: 

• Musculoskeletal condition which prevents 90-degree flexion of the knee or meets medical necessity for the tilt/recline feature on the shower/commode chair.

Indications for coverage of a heavy-duty shower/commode chair: 

• Documentation of the member's weight to determine justification.

Documentation Requirements: 

• Home Assessment
• Documentation to support that a less costly system will not meet the needs of the individual.
• A prescription from prescribing physician
• Physician's documentation needs to address medical necessity.
• If requesting for a member under 21 years old must address growth potential of item(s) requested.
• A prescription from prescribing physician/practitioner.
• Medical documentation supporting the need.
• Physician/practitioner exam within 90 days of the service authorization start date.

Date Revised:  March 2017

Reformatted and reviewed. 

Date Revised:  November 2019

Reviewed. Header logo replaced with new logo.

Revised Documentation Requirements section:

Deleted: 

• A prescription from prescribing physician
• Physician's documentation needs to address medical necessity.

Added:

• A prescription from prescribing physician/practitioner.
• Medical documentation supporting the need.
• Physician/practitioner exam per current DME Manual's requirements.

Date Revised:  November 23, 2023

Deleted: 

• Physician/practitioner exam per current DME Manual's requirements.

Added: 

• Physician/practitioner exam within 90 days of the service authorization start date.

Reviewed. Header logo replaced with new logo.

Service Authorization Required: Yes
CMN Required: None

Effective Date:  March 2007
Revised Date: December 2022

Indications for coverage and medical appropriateness:

• Bilirubin levels must be at or greater than 12.0 with bilirubin therapy within the first 30 days of life.
• Rental is for a maximum of seven 7 consecutive days, in a lifetime.

Documentation Requirements:

• A prescription from ordering physician/practitioner.
• Physician/practitioner exam within 90 days of the service authorization start date.
• Medical documentation supporting qualifying bilirubin levels.
• Physician/practitioner's documentation needs to address medical necessity.

Date Revised:  January 2017

Reviewed and revised.

Date Revised:  February 2020

Added new logo and added to Documentation Requirement section bullet #1, #2 and #4.

Date Revised:  December 22, 2022

Updated with new logo 

Service Authorization Required: No
CMN Required: None

Effective Date:  March 2007
Revised Date: November 2022

Indications and limitations of coverage and medical appropriateness:

Coverage allowed if ALL of the following conditions are present: 

• Diabetic (type I, II, or gestational), and
• The member has successfully completed training in the use of the monitor, test strips and lancets, and
• The device is designed for home use.

Guidance:

• One monitor allowed every four years, if replacement is needed.
• Lancets (A4259), blood glucose test strips (A4253) and control solutions (A4256) are covered items as well as the spring powered device (A4258) for lancets.
• Allowed up to 150 strips/lancets per month for insulin dependent diabetics.
• Allowed up to 200 strips/lancets every 3 months for non-insulin dependent diabetics.
• Allow one spring-powered device (A4258) every six months.

Non-Covered:

• Laser skin piercing device (E0620) is non-covered as not medically necessary. No exceptions.
• Alcohol, betadine, or peroxide is non-covered; since these items are not required for the proper functioning of the device. Urine test strips (A4250) are non-covered since they are not used with a glucose monitor. No exceptions.

Documentation Requirements:

• A prescription from ordering physician/practitioner.
• Physician/practitioner exam within 90 days of the service authorization start date that documentation supports the policy’s coverage criteria.

List of covered blood glucose monitors and billing guidance: 

Except for Medicare crossovers, ND Medicaid pays for blood glucose test strips, lancets, insulin syringes, and pen needles through pharmacy claims (see Preferred Diabetic Supply List).  Medicare crossover claims will be paid through DME provided Medicare pays first (see Medicare policy link). 

Date Revised:  January 2017

Reviewed and revised.

Date Revised:   November 2019

Reviewed and updated Coverage allowed section removed “There is a physician’s order for the monitor and supplies, and”. Documentation Required section deleted.  

Added: 

Documentation Requirements: 

• A prescription from prescribing physician/practitioner.
• Medical documentation supporting the need.
• Physician/practitioner exam per current DME Manual’s requirements.

Header logo replaced with new logo. 

Date Revised:   February 7, 2022

Reviewed and revised: 

Inserted in Documentation Requirements:

• A prescription from ordering physician/practitioner.
• Physician/practitioner exam within 90 days of the service authorization start date that documentation supports the policy’s coverage criteria.
• List of covered blood glucose monitors and billing guidance:
• Except for Medicare crossovers, ND Medicaid pays for blood glucose test strips, lancets, insulin syringes, and pen needles through pharmacy claims (see Preferred Diabetic Supply List).  Medicare crossover claims will be paid through DME provided Medicare pays first (see Medicare policy link).

Deleted in Documentation Requirements: 

• A prescription from prescribing physician/practitioner.
• Medical documentation supporting the need.
• Physician/practitioner exam per current DME Manual’s requirements.

Date Revised:   November 23, 2022

Reviewed and remains unchanged. Header logo updated with new logo. 

Service Authorization Required: Yes
CMN Required: None

Effective: March 2012
Revised: November 2022

Manual (E0602NU) and Electric (E0603NU) breast pumps should be used to promote lactation and to provide lactation support when natural feeding is not possible. These items are purchase only and do not require service authorization. 

Hospital grade electric breast pumps (E0604RR) do not require service authorization for the initial one-month rental. If additional months of rental is needed a service authorization is required. 

The Women, Infants, and Children's (WIC) Nutrition Program stocks a supply of hospital grade electric pumps. If the child is on the WIC program, the hospital grade breast pump must be obtained through the WIC Program as long as supply is available. 

Please note: If the member is in need of lactation services, North Dakota Medicaid encourages the member and provider to work together to contact the Women, Infants, and Children's (WIC) program. WIC is a program for pregnant women, breastfeeding women, infants, and children younger than five and is available in all counties in North Dakota. 

For more information or to find vour local WIC office please call 1-800-472-2286 or go to https://www.hhs.nd.gov/food-programs/WIC.

Indications and limitations of coverage and medical appropriateness:

Coverage Limits:

• Limited to one manual breast pump every year, or
• One electric breast pump every 3 years.
• All supplies necessary to operate the hospital grade electric breast pump are included in the monthly rental fee.

Documentation Requirements: 

• A prescription from ordering physician/practitioner.
• Physician/practitioner's documentation needs to address medical necessity.
• Physician/practitioner exam within 90 days of the service authorization start date.
• When submitting the service authorization for the hospital grade electric breast pump, providers will be required to include an item description. Item description is to include manufacturer name and item model number on the MMIS web portal service authorization note section.
• Types of hospital grade electric breast pumps considered for coverage include Medela Symphony Hospital Grade Breast Pump and Lactina Select Breast pump.

A service authorization of hospital grade electric breast pump beyond 1 month is required. Medicaid Utilization Review staff will review the records to determine if below criteria are met: 

• The hospital grade electric breast pump is still being utilized by the mother.
• Lactation cannot be initiated in the normal fashion or with a standard electric pump (E0603) because of conditions of the mother or baby, which prevent normal suckling. This includes but is not limited to prematurity, neonatal or maternal illness, neurological abnormalities, and anatomic abnormalities such as oro-facial or breast anomalies. The goal of the hospital grade pump is to simulate as closely as possible the normal maternal physical and physiologic response to suckling to enhance effective lactation and to produce sufficient milk for the infant's nutrition.
• Practitioner diagnosed medical/physical conditions that only require short term maternal pumping so there is no need for a purchased standard electric pump. These include mastitis, or maternal need for medications, which require pumping, and discarding the milk. The practitioner will be required to document the continued need for the pump for the originally specified condition on a monthly basis.

Date Revised:   January 2017

Reviewed and revised. 

Date Revised:   February 2020

Add new logo and added three bullets to the required documents - prescription, practitioner note and medical necessity. 

Date Revised:   November 2022

Reviewed and revised. Header logo updated with new logo. 

• Cane and Crutches
• Cervical Traction Home Device
• Chest Wall Oscillating Device (Airway Vest System)
• Cochlear Implants and Auditory Osseointegrated Implants (BAHA) Replacement Parts/Repair
• Cold Therapy
• Commodes and Chairs
• Continuous Glucose Monitor and Supplies
• Continuous Passive Motion Exercise
• Continuous Positive Airway Device
• Cranial Remolding Orthosis
• Diabetic Shoes and Inserts
• Eye Prosthesis
• Enclosed Bed
• Enteral Nutrition
• Exercise Equipment
• External Breast Prosthesis
• External Facial Prosthesis
• External Infusion Pump
• First Aid Supplies
• Gait Trainers/Walkers
• Hearing Aids
• Hospital Beds
• Incontinence Products (Adult and Youth)
• Insulin Pump
• Intermediate Care Facilities for Individuals with Intellectual Disabilities
• Nebulizers
• Negative Pressure Wound Therapy
• Non-Covered Items No Exceptions (Revised March 2019)
• Orthotics - Ankle-Foot and Knee-Ankle-Foot
• Orthopedic Shoes and Inserts
• Osteogenic Bone Growth Stimulator
• Ostomy Supplies
• Oxygen Equipment and Supplies (Revised March 2019)
• Parental Nutrition
• Patient Lift
• Pneumatic Pressure Devices
• Power Operated Vehicles
• Pressure Reducing Support Services
• Prosthetic Devices
• Pulse Oximeter and Supplies
• Respiratory Assist Device (BIPAP)
• SADD Light
• Seat Lift Mechanism
• Skilled Nursing Facility
• Speech Generating Device
• Standing Frame Stander
• Suction Pump and Supplies
• Surgical Dressings
• Swing Bed Facility
• TLSO/LSO
• Trach Care Kits
• Transcutaneous Electrical Nerve Stimulators (TENS)
• Urological Supplies
• Ventilator
• Wheelchair Manual or Power and Accessories