(e) The second and succeeding months of rental use, with the exception that all hearing aid or other assistive listening device rentals require prior authorization;.
(f) Purchase of any item which is not covered by medicareMedicare, part b, when prescribed for a recipient who is also eligible for medicare;Medicare.
(g) Any item required by a recipient in a nursing home which meets the requirements of subd. (4) (c); and.
(h) Purchase or rental of a hearing aid or other assistive listening device as followsin any of the following circumstances:
1. A request for prior authorization of a hearing aid or other ALD shall be reviewed only if the request consists of an otological report from the recipient’s physician and an audiological report from an audiologist or hearing instrument specialist, is on forms designated by the department and contains all information requested by the department. A hearing instrument specialist may perform an audiological evaluation and a hearing aid evaluation to be included in the audiological report if these evaluations are prescribed by a physician who determines thatall of the following:
a. The recipient is over the age of 21;.
b. The recipient is not cognitively or behaviorally impaired; and.
c. The recipient has no special need which would necessitate either the diagnostic tools of an audiologist or a comprehensive evaluation requiring the expertise of an audiologist;.
2. After a new or replacement hearing aid or other ALD has been worn for a 30−day trial period, the recipient shall obtain a performance check from a certified audiologist, a certified hearing instrument specialist or at a certified speech and hearing center. The department shall provide reimbursement for the cost of the hearing aid or other ALD after the performance check has shown the hearing aid or ALD to be satisfactory, or 45 days has elapsed with no response from the recipient;.
3. Special modifications other than those listed in the MA speech and hearing provider handbook shall require prior authorization; and.
4. Provision of services in excess of the life expectancies of equipment enumerated in the MA speech and hearing provider handbook require prior authorization, except for hearing aid or other ALD batteries and repair services.
SECTION 13. DHS 107.24 (3) (i) and (j) are created to read:
DHS 107.24 (3) (i) A request for prior authorization of complex rehabilitation manual wheelchairs, complex rehabilitation power wheelchairs, and other complex rehabilitation seating components shall be reviewed only if the request consists of all of the following:
1. Documentation of a complex rehabilitative technology clinical evaluation performed by a qualified health care professional that includes all of the following:
a. A detailed description of the qualified health care professional’s assessment as outlined in the provider handbook including identification of the specific complex rehabilitation technology items requested.
b. A detailed description of the medical necessity as defined in ss. DHS 101.03 (96m) and 107.02 (3) (e), for each complex rehabilitation technology request. c. The qualified health care professional’s signature and date of completion.
2. Documentation stating that a direct, on-premises complex rehabilitation technology evaluation was performed by a qualified complex rehabilitation technology professional that includes all of the following:
a. A detailed description of the recipient’s current durable medical equipment and requested complex rehabilitation technology items, the projected lifespan of both, the accessibility of the setting in which the requested items are to be used, the recipient’s applicable methods of transportation, and an analysis of at least one comparable alternative to each requested item including an explanation of why the alternative does not meet the recipient’s needs.
b. A statement asserting that the qualified complex rehabilitation technology professional will provide appropriate training to the recipient and will maintain adequate documentation of the training provided.
c. A statement indicating presence at the recipient’s complex rehabilitation technology clinical evaluation or other coordination with the qualified health care provider conducting the complex rehabilitation clinical evaluation to assist in selection of the most appropriate complex rehabilitation technology item.
d. The qualified complex rehabilitation technology professional’s signature and date of completion.
3. A signed statement from each qualified health care professional, who performs the complex rehabilitation technology clinical evaluation, providing documentation of a complex rehabilitation technology clinical evaluation in subd. 1. indicating he or she does not have a financial relationship with the complex rehabilitation technology supplier providing the requested items.
DHS 107.24 (3) (j) A request for prior authorization of all complex rehabilitation technology not included in par. (i) shall be reviewed only if the request complies with MA policy and procedures as described in MA provider handbooks and bulletins and includes a detailed description of the medical necessity, as defined in s. DHS 101.03 (96m), of the complex rehabilitation technology requested. SECTION 14. DHS 107.24 (4) (i) is created to read:
DHS 107.24 (4) (i) Reimbursement for complex rehabilitation technology is limited to qualified complex rehabilitation technology suppliers.
SECTION 15. DHS 107.24 (5) (b) is amended to read:
DHS 107.24 (5) (b) Services denied by both medicareMedicare and MA for lack of medical necessity.
SECTION 16. Effective date. This rule shall take effect on the first day of the month following publication in the Wisconsin Administrative Register, as provided in § 227.22 (2) (intro.), Stats.
