Rule 5160-10-21 | DMEPOS: incontinence garments and related supplies.
(A) Coverage.
(1) Payment for quantities of incontinence garments or incontinence supplies that exceed the indicated limit is subject to prior authorization (PA). The default certificate of medical necessity (CMN) form is the ODM 02912, "Certificate of Medical Necessity: Incontinence Items" (rev. 7/2024). The CMN includes the following elements:
(a) An indication that the individual is at least thirty-six months of age;
(b) The applicable diagnosis of the specific disease, injury, developmental delay, or developmental disability causing the incontinence;
(c) The type of incontinence; and
(d) The type and quantity of incontinence garments or incontinence supplies being prescribed.
(2) An increase in the prescribed quantity of an incontinence item is subject to PA, as is a change in the type of incontinence item. (No additional authorization is needed for a decrease in quantity.)
(3) Similar types of incontinence garments (e.g., briefs/diapers and underwear/pull-ons) may be dispensed together without PA if the aggregate quantity does not exceed the prescribed quantity or indicated limit for any of the individual items.
(B) Constraints and limitations.
(1) Payment cannot be made for items related to stress incontinence to which no specific physiological, psychological, or physiopsychological cause can be attributed.
(2) PA cannot be granted for longer than twelve months at a time.
(3) Incontinence items are dispensed in quantities representing one month's supply. A provider is expected to verify and document an individual's current need before dispensing additional items. Medicaid payment for excessive quantities of items is subject to recovery.
(4) Payment will not be made for more incontinence items than are prescribed or authorized.
Last updated July 2, 2024 at 10:45 AM
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