Changes to DME, Orthotics, Prosthetics and Supplies Authorization Requirements

Date: 12/16/16

We are writing to advise you of some important changes to our DME, Orthotics, Prosthetics and Supplies prior authorization requirements for services provided to members of MHS Health Wisconsin Medicaid SSI and BadgerCare, Network Health Medicaid SSI and BadgerCare and MHS Health Wisconsin Advantage HMO SNP. 

Procedure Code                    Procedure Description

A4210                      NEEDLE-FREE INJECTION DEVICE, EACH

A6511                      COMPRS BRN GARMNT LW TRNK LEG OPN

A9277                      TRANSMITTER: EXT INTERSTITIAL CONT GLU MON SYS

A9278                      RECEIVER MON: EXT INTERSTITIAL CONT GLU MON SYS

E0465                      HOME VENT ANY TYPE USED INVASV INTF

E0466                      HOME VENT TYPE USED NON-INVASV INTF

E0574                      US/ELEC AROSL GEN W/SM VOLUME NEB

E0628                      SEPARATE SEAT LIFT MECHANISM FOR USE WITH PATIENT OWNED FURNITURE-ELEC

E0958                      WHEELCHAIR ATTACHMENT TO CONVERT ANY WHEELCHAIR

E0986                      MANUAL WHEELCHAIR ACCESSORY, PUSH-RIM ACTIVATED POWER ASSIST, EACH

E1012                      WC ACCESS PWR SEAT SYS CNTR MNT EA

E1030                      WHEELCHAIR ACCESSORY, VENTILATOR TRAY, GIMBALED

E1806                      SPS WRIST DEVICE

E1841                      STATIC STR SHLDR DEV ROM ADJ

K0609                      AUTOMATIC EXTRNL DFBRLLTR, W INTGRTD ELECRDGRM ANALYSIS

L2180                      ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, PLASTIC SHOE INSERT WIT

L2540                      ADDTN;THIGH-WEIGHT BEARING,LACER,MOLDED TO PATIENT MODEL

L3981                      UE FX ORTH SHOUL CAP FOREARM

L6026                      PART HAND MYO EXCLU TERM DEV

L7259                      ELECTRONIC WRIST ROTATOR ANY

L7364                      TWELVE VOLT BATTERY UTAH/EQU

Q4111                     GAMMAGRAFT SKIN SUB

V5246                      HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, ITE (IN THE EAR)

V5247                      HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, BTE(BEHIND EAR)

V5298                      HEARING AID, NOT OTHERWISE CLASSIFIED

Please note: this list is not all-inclusive. To avoid claim denials for lack of authorization, please check specific HCPCS codes by using the “Medicaid Pre-Auth Needed?” function on our website:

http://www.mhswi.com/for-providers/pre-auth-needed/medicaid-pre-auth-needed.  

If you have any questions, please call Provider Services at 1-800-222-9831.