Fall Prevention Benefit (in-home assessment and bathroom safety DME)
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Defines coverage, prior authorization, and eligibility for an in-home safety assessment and associated bathroom safety durable medical equipment for AllCare Advantage members.
No material clinical or coverage changes in this revision.
Coverage Criteria for In-Home Assessment and Bathroom Safety DME
In-home safety assessment (T1028) — coverage criteria
Covered when ALL of the following are met:
If the PA request is initiated by the member, the request must be supported by the PCP/treating provider and documented via the Beneficiary Initiated Request (BIR) process; UM Analyst will verify provider recommendation if request not submitted by provider.
If CDC screening score is 3 or less, UM will refer to RN to determine if a comorbid condition justifies approval.
Bathroom safety DME — coverage criteria (installation following assessment)
Covered when ALL of the following are met after an approved in‑home assessment:
Only one bathroom in the home may be assessed and receive covered device installation per calendar year.
This benefit permits only one bathroom assessment per calendar year. The policy states that once a member meets the criteria for the in‑home safety assessment, they are eligible for installation of recommended bathroom safety devices, and explicitly limits the benefit to one bathroom in the home to have an assessment per calendar year.
If the CDC Fall Prevention risk screening score is 3 or less, the request is routed to nursing review. Nursing will determine whether the member has a comorbid medical condition that could benefit from a home safety evaluation; if such a comorbid condition is present the assessment may be approved, and if not, the request may be denied as not meeting criteria.
Coding and Screening Details
| T1028 | Home environment assessment |
| A9901 | DME delivery, mileage, set up, and/or dispensing service |
| E0240 | Bath or shower chair |
| E0241 | Bathtub wall rail |
| E0242 | Bathtub floor rail |
| E0243 | Toilet rail |
| E0244 | Raised toilet seat |
| E0245 | Tub stool or bench |
| E0246 | Transfer tub rail attachment |
| E0247 | Transfer bench for tub or toilet with or without commode opening |
| E1399 | Portable Air Purifier / Air filters (CCO only) |
Provider Requirements and Prior Authorization
Prior authorization required for in-home safety assessment (T1028)
Prior authorization (PA) is required for the in‑home safety assessment billed with HCPCS code T1028. Providers must submit PA requests via the AllCare Health Provider portal or by fax; member-initiated requests require a completed Beneficiary Initiated Request (BIR) form and supporting PCP/treating provider documentation. All PA requests are reviewed by Utilization Management.
- PA for the in-home safety assessment (T1028) is required.
- Provider-submitted PAs: AllCare Health Provider portal or fax.
- Member-submitted PAs: receiving staff must complete BIR form and the request must be supported by the PCP/treating provider.
- All PAs reviewed by Utilization Management.
Provider or member may initiate PA; verify provider recommendation
Providers may initiate PA requests and must respond to Utilization Management inquiries; if a PA is submitted by a member, UM will contact the PCP/treating provider to verify the assessment recommendation and may forward to nursing for denial if the provider cannot be confirmed.
- A Provider or member may initiate the PA request.
- If member-submitted, the UM Analyst will contact the PCP/treating provider to verify recommendation; if unable to confirm, send to RN and RN may deny.
Required documentation and support for PA requests
PA requests for the in‑home safety assessment must include a PCP or treating provider recommendation; member-initiated requests require the BIR form and documented PCP/treating provider support. If the PCP/treating provider recommendation cannot be confirmed for member-submitted requests, the request may be denied.
- PCP or treating provider recommendation required for PA.
- Member-initiated requests: complete BIR form and include PCP/treating provider support.
- UM Analyst will verify provider recommendation for member-submitted requests; inability to confirm may lead to RN review/denial.
Denial triggers — low CDC screening score without comorbidity
A request may be denied if the CDC Fall Prevention risk screening score is 3 or less and the member does not have a comorbid medical condition that could benefit from a home safety evaluation; such cases are referred to nursing and denied if no qualifying comorbidity is present.
- CDC screening score of 3 or less → refer to RN.
- RN will approve only if a comorbid medical condition that could benefit from evaluation is present; otherwise deny for not meeting criteria.
Medical Necessity for DME
DME medical necessity
DME is medically necessary when ALL of the following are satisfied:
Support must be documented at time of PA or following assessment; member-initiated requests require PCP/treating provider support and BIR documentation.
Coverage limited to devices recommended via the approved assessment and to one bathroom per calendar year.
Rental and Purchase Rules for Bathroom Safety DME
| Equipment / HCPCS | Rental vs Purchase rule |
|---|---|
| T1028 - Home environment assessment | |
| unspecified | |
| A9901 - DME delivery, mileage, set up, and/or dispensing service | |
| unspecified | |
| E0240 - Bath or shower chair | |
| unspecified | |
| E0241 - Bathtub wall rail | |
| unspecified | |
| E0242 - Bathtub floor rail | |
| unspecified | |
| E0243 - Toilet rail | |
| unspecified | |
| E0244 - Raised toilet seat | |
| unspecified | |
| E0245 - Tub stool or bench | |
| unspecified | |
| E0246 - Transfer tub rail attachment | |
| unspecified | |
| E0247 - Transfer bench for tub or toilet with or without commode opening | |
| unspecified | |
| E0248 - Transfer bench, heavy duty, for tub or toilet with or without commode opening | |
| unspecified | |
| E0163 - Commode chair, mobile or stationary, with fixed arms | |
| unspecified | |
| E0165 - Commode chair, mobile or stationary, with detachable arms | |
| unspecified | |
| E0700 - Handheld shower wand | |
| unspecified |
Replacement Rules
Definitions
Documentation Requirements
Document assessor recommendations and PCP/treating provider support
Document the assessor’s specific device recommendations and include PCP or treating provider support either at the time of PA submission or after the assessment; UM may require verification of the provider recommendation for member‑initiated requests.
- Assessor must record specific device recommendations from the in‑home assessment.
- PCP/treating provider support must be documented at PA submission or following the assessment.
- For member-submitted requests, UM will verify provider recommendation; inability to confirm may result in denial.
Exclusions / Not Covered
Devices or installations for additional bathrooms beyond the single allowed assessment are not covered under this benefit within the same calendar year. The policy’s one‑bathroom limit means that equipment or installations for more than one bathroom in the same calendar year are excluded from coverage under this Fall Prevention benefit.
Background
The Fall Prevention benefit covers an in‑home safety assessment (T1028) performed by a contracted provider, followed by installation of recommended bathroom safety devices when criteria are met. Coverage requires a PCP or treating provider recommendation and a prior authorization for the in‑home assessment. Prior authorization requests may be initiated by a provider or a member (member requests must be supported by the PCP/treating provider and documented via the Beneficiary Initiated Request form); all requests are reviewed by Utilization Management. An approved assessment with specific device recommendations and PCP/treating provider support authorizes coverage of bathroom safety DME for the assessed bathroom (subject to the one bathroom per calendar year limit).
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