DHS 107.24(4)(c)2. 2. Durable medical equipment which is personalized in nature or custom-made for a recipient and is to be used by the recipient on an individual basis for hygienic or other reasons. These items are orthoses, prostheses including hearing aids or other assistive listening devices, orthopedic or corrective shoes, and complex rehabilitation technology. For coverage and reimbursement complex rehabilitation technology shall be prescribed by a physician, require prior authorization to establish medically necessity, and meet all complex rehabilitation standards under sub. (3) (i). In order to be covered for a recipient who is a nursing home resident, the complex rehabilitation technology shall do at least one of the following:

DHS 107.24(4)(c)2.a. a. Contribute to the recipient’s independent completion of activities of daily living.

DHS 107.24(4)(c)2.b. b. Support the recipient’s occupational, vocational, or psychosocial activities.

DHS 107.24(4)(c)2.c. c. Provide the recipient the independent ability to move about the facility, or to attain or retain self-care.

DHS 107.24(4)(d) (d) The provider shall weigh the costs and benefits of the equipment and supplies when considering purchase or rental of DME and medical supplies.

DHS 107.24 Note Note: The program’s listing of covered services and the maximum allowable reimbursement schedules are based on basic necessity. Although the program does not intend to exclude any manufacturer of equipment, reimbursement is based on the cost-benefit of equipment when comparable equipment is marketed at less cost. Several medical supply items are reimbursed according to generic pricing.

DHS 107.24(4)(e) (e) The department may determine whether an item is to be rented or purchased on behalf of a recipient. In most cases equipment shall be purchased; however, in those cases where short-term use only is needed or the recipient’s prognosis is poor, only rental of equipment shall be authorized.

DHS 107.24(4)(f) (f) Orthopedic or corrective shoes or foot orthoses shall be provided only for postsurgery conditions, gross deformities, or when attached to a brace or bar. These conditions shall be described in the prior authorization request.

DHS 107.24(4)(g) (g) Provision of hearing aid accessories shall be limited as follows:

DHS 107.24(4)(g)1. 1. For recipients under age 18: 3 earmolds per hearing aid, 2 single cords per hearing aid and 2 Y-cords per recipient per year;

DHS 107.24(4)(g)2. 2. For recipients over age 18: one earmold per hearing aid, one single cord per hearing aid and one Y-cord per recipient per year; and

DHS 107.24(4)(g)3. 3. For all recipients: one harness, one contralateral routing of signals (CROS) fitting, one new receiver per hearing aid and one bone-conduction receiver with headband per recipient per year.

DHS 107.24(4)(h) (h) If a prior authorization request is approved, the person shall be eligible for MA reimbursement for the service on the date the final ear mold is taken.

DHS 107.24(4)(i) (i) Reimbursement for complex rehabilitation technology is limited to qualified complex rehabilitation technology suppliers.

DHS 107.24(4)(j) (j) The cost of mailing or delivery, such as shipping and handling charges and fees, of diagnostic tools or equipment needed to assess, diagnose, repair or setup medical supplies, hearing aids, cochlear implants, or other equipment cannot be billed to the recipient.

DHS 107.24(5) (5) Non-covered services. The following services are not covered services:

DHS 107.24(5)(a) (a) Foot orthoses or orthopedic or corrective shoes for the following conditions:

DHS 107.24(5)(a)1. 1. Flattened arches, regardless of the underlying pathology;

DHS 107.24(5)(a)2. 2. Incomplete dislocation or subluxation metatarsalgia with no associated deformities;

DHS 107.24(5)(a)3. 3. Arthritis with no associated deformities; and

DHS 107.24(5)(a)4. 4. Hypoallergenic conditions;

DHS 107.24(5)(b) (b) Services denied by both Medicare and MA for lack of medical necessity.

DHS 107.24(5)(c) (c) Items which are not primarily medical in nature, such as dehumidifiers and air conditioners;

DHS 107.24(5)(d) (d) Items which are not appropriate for home usage, such as oscillating beds;

DHS 107.24(5)(e) (e) Items which are not generally accepted by the medical profession as being therapeutically effective, such as a heat and massage foam cushion pad;

DHS 107.24(5)(f) (f) Items which are for comfort and convenience, such as cushion lift power seats or elevators, or luxury features which do not contribute to the improvement of the recipient’s medical condition;

DHS 107.24(5)(g) (g) Repair, maintenance or modification of rented durable medical equipment;

DHS 107.24(5)(h) (h) Delivery or set-up charges for equipment as a separate service;

DHS 107.24(5)(i) (i) Fitting, adapting, adjusting or modifying a prosthetic or orthotic device or corrective or orthopedic shoes as a separate service;