DHS 107.24(3)(f) (f) Purchase of any item which is not covered by Medicare, part b, when prescribed for a recipient who is also eligible for Medicare.

DHS 107.24(3)(g) (g) Any item required by a recipient in a nursing home which meets the requirements of sub. (4) (c).

DHS 107.24(3)(h) (h) Purchase or rental of a hearing aid or other assistive listening device in any of the following circumstances:

DHS 107.24(3)(h)1. 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 all of the following:

DHS 107.24(3)(h)1.a. a. The recipient is over the age of 21.

DHS 107.24(3)(h)1.b. b. The recipient is not cognitively or behaviorally impaired.

DHS 107.24(3)(h)1.c. 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.

DHS 107.24(3)(h)2. 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.

DHS 107.24(3)(h)3. 3. Special modifications other than those listed in the MA speech and hearing provider handbook shall require prior authorization.

DHS 107.24(3)(h)4. 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.

DHS 107.24(3)(i) (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:

DHS 107.24(3)(i)1. 1. Documentation of a complex rehabilitative technology clinical evaluation performed by a qualified health care professional that includes all of the following:

DHS 107.24(3)(i)1.a. 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.

DHS 107.24(3)(i)1.b. 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.

DHS 107.24(3)(i)1.c. c. The qualified health care professional’s signature and date of completion.

DHS 107.24(3)(i)2. 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:

DHS 107.24(3)(i)2.a. 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.

DHS 107.24(3)(i)2.b. 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.

DHS 107.24(3)(i)2.c. 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.

DHS 107.24(3)(i)2.d. d. The qualified complex rehabilitation technology professional’s signature and date of completion.

DHS 107.24(3)(i)3. 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) (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.

DHS 107.24 Note Note: For more information on prior authorization, see s. DHS 107.02 (3).

DHS 107.24(4) (4) Other limitations.

DHS 107.24(4)(a) (a) Payment for medical supplies ordered for a patient in a medical institution is considered part of the institution’s cost and may not be billed directly to the program by a provider. Durable medical equipment and medical supplies provided to a hospital inpatient to take home on the date of discharge are reimbursed as part of the inpatient hospital services. No recipient may be held responsible for charges or services in excess of MA coverage under this paragraph.

DHS 107.24(4)(b) (b) Prescriptions shall be provided in accordance with s. DHS 107.02 (2m) (b) and may not be filled more than one year from the date the medical equipment or supply is ordered.

DHS 107.24(4)(c) (c) The services covered under this section are not covered for recipients who are nursing home residents except for:

DHS 107.24(4)(c)1. 1. Oxygen. Prescriptions for oxygen shall provide the required amount of oxygen flow in liters.

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: