Section R9-22-212. Durable Medical Equipment, Orthotic and Pros- thetic Devices, and Medical Supplies

A.      Durable medical equipment, orthotic and prosthetic devices, and medical supplies, including incontinence briefs as speci- fied in subsection (E), are covered services to the extent per- mitted in this Section if provided in compliance with requirements of this Chapter; and

1.        Prescribed by the primary care provider, attending physi- cian, or practitioner; or

2.        Prescribed by a specialist upon referral from the primary care provider, attending physician, or practitioner; and

3.        Authorized as required by the Administration, contractor, or contractor’s designee.

B.       Covered medical supplies are consumable items that are designed specifically to meet a medical purpose, are dispos- able, and are essential for the member’s health.

C.      Covered DME is any item, appliance, or piece of equipment that is not a prosthetic or orthotic; and

1.        Is designed for a medical purpose, and is generally not useful to a person in the absence of an illness or injury, and

2.        Can withstand repeated use, and

3.        Is generally reusable by others.

D.      Prosthetics are devices prescribed by a physician or other licensed practitioner to artificially replace missing, deformed or malfunctioning portion of the body. Only those prosthetics that are medically necessary for rehabilitation are covered, except as otherwise provided in R9-22-215.

E.       The following limitations on coverage apply:

1.        The DME is furnished on a rental or purchase basis, whichever is less expensive. The total expense of renting the DME does not exceed the cost of the DME if pur- chased.

2.        Reasonable repair or adjustment of purchased DME is covered if necessary to make the DME serviceable and if the cost of repair or adjustment is less than the cost of renting or purchasing another unit.

3.        A change in, or addition to, an original order for DME is covered if approved by the prescriber in subsection (A), or prior authorized by the Administration or contractor, and the change or addition is indicated clearly on the order and initialed by the vendor. No change or addition to the original order for DME may be made after a claim for services is submitted to the member’s contractor, or the Administration, without prior written notification of the change or addition to the Administration or the con- tractor.

4.        Reimbursement for rental fees shall terminate:

a.         No later than the end of the month in which the pre- scriber in subsection (A) certifies that the member no longer needs the DME;

b.        If the member is no longer eligible for AHCCCS services; or

c.         If the member is no longer enrolled with a contrac- tor, with the exception of transitions of care as spec- ified in R9-22-509.

5.        Except for incontinence briefs for persons over 3 years old and under 21 years old as provided in subsection (E)(6), personal care items including items for personal cleanliness, body hygiene, and grooming are not covered unless needed to treat a medical condition. Personal care

items are not covered services if used solely for preven- tive purposes.

6.        Incontinence briefs, including pull-ups are covered to prevent skin breakdown and enable participation in social, community, therapeutic and educational activities under the following circumstances:

a.         The member is over 3 years old and under 21 years old;

b.        The member is incontinent due to a documented dis- ability that causes incontinence of bowel or bladder, or both;

c.         The PCP or attending physician has issued a pre- scription ordering the incontinence briefs;

d.        Incontinence briefs do not exceed 240 briefs per month unless the prescribing physician presents evi- dence of medical necessity for more than 240 briefs per month for a member diagnosed with chronic diarrhea or spastic bladder;

e.         The member obtains incontinence briefs from pro- viders in the contractor’s network;

f.         Prior authorization has been obtained as required by the Administration, contractor, or contractor’s desig- nee. Contractors may require a new prior authoriza- tion to be issued no more frequently than every 12 months. Prior authorization for a renewal of an existing prescription may be provided by the physi- cian through telephone contact with the member rather than an in-person physician visit. Prior autho- rization will be permitted to ascertain that:

i.         The member is over age 3 and under age 21;

ii.        The member has a disability that causes incon- tinence of bladder or bowel, or both;

iii.      A physician has prescribed incontinence briefs as medically necessary. A physician prescrip- tion supporting medical necessity may be required for specialty briefs or for briefs differ- ent from the standard briefs supplied by the contractor; and

iv.       The prescription is for 240 briefs or fewer per month, unless evidence of medical necessity for over 240 briefs is provided.

7.        First aid supplies are not covered unless they are provided in accordance with a prescription.

8.        The following services are not covered for individuals 21 years of age or older:

a.         Hearing aids;

b.        Prescriptive lenses unless they are the sole visual prosthetic device used by the member after a cata- ract extraction;

c.         Bone Anchor Hearing Aid (BAHA);

d.        Cochlear implant;

e.         Percussive vest;

f.         Insulin pump;

g.        Microprocesser-controlled lower limbs or micropro- cessor-controlled joints for lower limbs; and

h.        Orthotics, which are defined as devices that are pre- scribed by a physician or other licensed practitioner of the healing arts to support a weak or deformed portion of the body.

F.       Liability and ownership.

1.        Purchased DME that is provided to a member and no lon- ger needed by the member may be disposed of in accor- dance with each contractor’s policy.

2.        The Administration shall retain title to purchased DME provided to a member who becomes ineligible or no lon- ger requires use of the DME.

Arizona Health Care Cost Containment System - Administration

3.        If customized DME is purchased by the Administration or contractor for a member, the equipment shall remain with the person during times of transition to a different contractor, or upon loss of eligibility. For purposes of this subsection, customized DME refers to equipment that is altered or built to specifications unique to a member’s medical needs and that, most likely, cannot be used or reused to meet the needs of another individual.

4.        A member shall return DME obtained fraudulently to the Administration or the contractor.

Historical Note

Adopted as an emergency effective May 20, 1982 pursu- ant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82- 3). Former Section R9-22-212 adopted as an emergency now adopted and amended as a permanent rule effective August 30, 1982 (Supp. 82-4). Former Section R9-22- 212 repealed, new Section R9-22-212 adopted effective October 1, 1983 (Supp. 83-5). Amended effective Octo-

ber 1, 1985 (Supp. 85-5). Amended subsection (B), para- graph (2), and deleted subsection (C) effective October 1, 1986 (Supp. 86-5). Section repealed, new Section adopted effective September 22, 1997 (Supp. 97-3).

Amended by final rulemaking at 8 A.A.R. 2325, effective May 9, 2002 (Supp. 02-2). Amended by final rulemaking

at 13 A.A.R. 3272, effective September 11, 2007 (Supp. 07-3). Amended by exempt rulemaking at 16

A.A.R. 1638, effective October 1, 2010 (Supp. 10-3).