CurrentCareSourcePolicy N/A

Durable Medical Equipment and Wheelchair Accessories for Medicaid (PASSE)

Lists coverage decisions (mostly approvals) for durable medical equipment (DME), wheelchair components/accessories, enteral nutrition supplies, and incontinence products for CareSource Medicaid PASSE members. Affects DME providers and Medicaid members covered by CareSource.

Policy Summary

PayerCareSource

PolicyDurable Medical Equipment and Wheelchair Accessories for Medicaid (PASSE)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFor listed DME and wheelchair accessories, billers/providers should follow documented approval decisions (items shown as Approved for Medicaid PASSE members).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

manyItems Approved

MedicaidPayer

G809Frequent Dx

ApprovedCoverage Status

pediatricFocus

~20+

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Approved Items

Approved DME/wheelchair/accessory items

Line-item approvals and associated provider specialty and diagnosis context

K0019 Arm pad, each — Decision: Approved; Provider specialty: Durable Medical Equipment; Associated diagnosis: G809 / 6809 (Cerebral palsy, unspecified).

K0108 Wheelchair component or accessory, not otherwise specified — Decision: Approved; Provider specialty: Durable Medical Equipment; Associated diagnosis: G809 / 6809 (Cerebral palsy, unspecified).

E2294 Seat, contoured, for pediatric size wheelchair including fixed attaching hardware — Decision: Approved; Provider specialty: Durable Medical Equipment; Associated diagnosis: G809 / 6809 (Cerebral palsy, unspecified).

B9002 Enteral nutrition infusion pump with alarm — Decision: Approved; Provider specialty: Durable Medical Equipment; Associated diagnosis: G809 / 6809 (Cerebral palsy, unspecified).

Medicaid-approved DME items with associated diagnosis codes

Items listed in these chunks are marked as 'Approved' for Medicaid and tied to specific diagnosis codes.

E2294 — Contoured pediatric wheelchair seat including fixed attaching hardware; Coverage: Approved; Example associated diagnoses: G809, G800, G801 (cerebral palsy variants).

E2510 — Speech generating device, synthesized speech; Coverage: Approved; Example associated diagnoses: Q909 (Down syndrome), 29911 (dependence on respirator/ventilator).

E1390 — Oxygen concentrator, single delivery port (capable of delivering ≥85% oxygen) — Coverage: Approved; Associated diagnoses include respiratory dependence/obstructive sleep apnea entries cited in the table.

E0445 — Oximeter device for measuring blood oxygen levels noninvasively — Coverage: Approved; Associated with respiratory diagnoses and portable oxygen entries.

E0971 — Manual wheelchair accessory; antitipping device — Coverage: Approved; Associated diagnoses include developmental and cerebral palsy codes referenced in the excerpt.

Diagnosis-to-item approval mappings

Items listed with associated diagnoses are denoted as Approved under Medicaid in this document segment.

Mapping example — Diagnoses: G800 / G808 / J9601 / R6250 etc.; Items approved: E1234 (pediatric tilt-in-space wheelchair), E2231 (solid seat support base), E1390 (oxygen concentrator), E0430 (portable gaseous oxygen system).

Multiple entries repeat Approved status for these pairings.

Approved DME and supplies (excerpt)

The document fragment enumerates DME items and accessories associated with diagnosis codes and marks them as Approved for Medicaid.

E1390 — Oxygen concentrator, single delivery port — Coverage: Approved for Medicaid; requirement: capable of delivering ≥85% oxygen at prescribed flow rate (see specific entries).

E0430 — Portable gaseous oxygen system (purchase includes regulator, flowmeter, humidifier, cannula/mask, and tubing) — Coverage: Approved for Medicaid; tied to chronic respiratory failure / hypoxia and sleep apnea diagnoses.

E0445 — Oximeter device — Coverage: Approved for Medicaid; associated with hypoxia/chronic respiratory failure and portable oxygen entries.

E2293 — Back, contoured, for pediatric size wheelchair including fixed attaching hardware — Coverage: Approved for Medicaid across pediatric cerebral palsy entries.

B4160 — Enteral formula for pediatrics, nutritionally complete, calorically dense (>=0.7 kcal/ml) — Coverage: Approved for Medicaid; associated with metabolic/gastrostomy status entries.

Approved DME by diagnosis (excerpt)

When paired with listed diagnoses, the following DME items are approved:

E0430 (portable gaseous oxygen system) — Approved when associated with unspecified chronic respiratory disease (P279), respiratory syncytial virus pneumonia (J121), gastrostomy status and other listed diagnoses.

E0445 (Oximeter) — Approved when associated with respiratory diagnoses such as P279 and when listed alongside portable oxygen systems.

E1237 (pediatric rigid adjustable wheelchair) — Approved when associated with G800 (spastic quadriplegic cerebral palsy) and related pediatric mobility diagnoses.

E2293 (contoured pediatric wheelchair back) — Approved across multiple developmental and neurologic diagnoses in pediatric wheelchair entries.

E2510 (speech generating device) — Approved when associated with developmental disorders (e.g., F842/autism spectrum entries) and diagnoses requiring augmentative communication.

DME coverage criteria (excerpt)

Coverage approvals shown in tabular PASSE/Medicaid entries linking diagnoses/status to DME codes.

Rule r1: E0430 (portable gaseous oxygen system) is listed and marked Approved for multiple Medicaid PASSE diagnosis entries.

Rule r2: E1390 (oxygen concentrator) is listed with the performance requirement: capable of delivering ≥85% oxygen concentration at the prescribed flow rate; shown Approved in multiple entries.

Rule r3: Wheelchair accessories (E1028, K0108, E0955, etc.) are listed and marked Approved for members with cerebral palsy and related diagnoses.

Rule r4: Enteral supplies and formulas (B9998, B9002, B4160, B4034) are linked to gastrostomy or metabolic conditions and shown Approved.

Rule r5: Respiratory equipment (E0445 oximeter, respiratory suction pumps, E0465 home ventilator) are listed and approved for tracheostomy and chronic respiratory failure diagnoses.

Excerpted coverage pairings

Examples of diagnosis-to-item mappings and approval status found in excerpt:

Chronic respiratory failure with hypoxia — Approved items: E1390 (oxygen concentrator), E0431 (portable oxygen rental), E0445 (oximeter).

Tracheostomy dependence / ventilator dependence — Approved items: E0465 (home ventilator), E0430 (portable gaseous oxygen system) and related respiratory supplies.

Obstructive sleep apnea (adult/pediatric) — Approved items/services: E0601 (CPAP), E1390/E0430 (oxygen equipment); polysomnography codes (95810/95811) approved in Hospital/Acute Care setting.

Gastrostomy status / dysphagia / metabolic disorders — Approved items: B4160 (calorically dense pediatric enteral formula), B9998 (NOC enteral supplies), B4034 (enteral feeding supply kit).

Sample coverage mappings

Examples of coverage entries from the excerpt

95810 Polysomnography (attended by technologist) — Setting: Hospital/ Acute Care; Status: Approved (linked to sleep apnea diagnoses).

95811 Polysomnography with initiation of CPAP/BiPAP — Setting: Hospital/ Acute Care; Status: Approved.

97530 Therapeutic activities — Linked to developmental speech/motor diagnoses; Status: Approved (used per 15-minute units).

Approvals in fragment

Codes and associated diagnoses shown in this fragment are marked as Approved for Medicaid and the Hospital/Acute Care setting

Chemodenervation codes (64643, 64645) — Status: Approved; Notes: Listed as approved in Hospital/Acute Care portions of the excerpt.

Facet joint injection codes (64490, 64491) with image guidance — Status: Approved; Setting: Hospital/Acute Care.

Therapy and modality CPTs (97110, 97530, 97032, 97035, 97112) — Status: Approved for cerebral palsy and related diagnoses; typically listed in Hospital/Acute Care context.

Approved OPAS procedures and diagnoses

Listed diagnoses and procedures with OPAS setting and approval status

OPAS (Outpatient Ambulatory Services) entries — Codes such as 95810, 95811, 64643, 64733, 97110, 97112, 97116, 97032 are shown under OPAS with '999 units' indicator and status Approved; action: bill under OPAS for indicated diagnoses as shown.

Diagnosis-to-service approval mapping (behavioral health/therapy)

When diagnosis matches listed behavioral health or therapy conditions, the associated CPT codes are approved for outpatient behavioral health or therapy services.

If diagnosis is one of the listed behavioral/therapy conditions (examples: F802, F339, F913, F411, F432x, F902, F6381), then services in an Outpt Behav Hlth Agency (90791, 90792, 90832, 90834, 90837, 90846, 90847, 92507, 97110, 97530) are Approved.

Diagnosis-to-Service Approvals (sample nodes)

Diagnosis-to-service mappings shown as Approved for Medicaid members in an outpatient behavioral health agency setting.

F339 (Major depressive disorder, recurrent) — Approved services: 90832, 90834, 90837, 90791 (psychotherapy and psychiatric diagnostic evaluation) when provided in an Outpt Behav Hlth Agency; Office Visit authorization field referenced for number of visits authorized.

Rehab and Speech Therapy Approvals

Rehabilitative and therapy services mapped to developmental, motor, speech and related diagnoses.

For diagnoses such as F82, G800, G809, Q054 (developmental/motor conditions), approved services include 97530 (therapeutic activities), 97110 (therapeutic exercises), and 92507 (speech therapy) when delivered in an Outpt Behav Hlth Agency; Status: Approved.

Medicaid Personal Care Coverage Criteria

Medicaid coverage stance for personal care services:

Personal care services (T1019 / T1019U3) billed per 15 minutes are Approved for Medicaid when provided as part of the individualized plan of treatment.

Personal care services are not payable when provided to an inpatient or resident of a hospital, nursing facility, ICF/MR or IMD.

Documented associated diagnoses appearing with Approved personal care services include examples such as epilepsy, COPD, cerebral palsy, bipolar disorder, CKD, Angelman syndrome and other developmental/medical conditions.

HCPCS / CPT / Procedure Codes and Key Coding Facts

Frequently referenced HCPCS/CPT-like codesmixedCovered

K0108	Wheelchair component or accessory, not otherwise specified
E2294	Seat, contoured, for pediatric size wheelchair including fixed attaching hardware
E0955	Wheelchair accessory; headrest; cushioned, any type; including fixed mounting hardware
B9002	Enteral nutrition infusion pump with alarm

Selected DME and wheelchair-related HCPCS codesHCPCSCovered

E2294	Seat, contoured, for pediatric size wheelchair including fixed attaching hardware
E2323	Power wheelchair accessory, specialty joystick handle for hand control interface prefabricated
E2510	Speech generating device, synthesized speech
E1390	Oxygen concentrator, single delivery port, capable of delivering ≥85% oxygen
E0445	Oximeter device for measuring blood oxygen levels noninvasively
K0108	Wheelchair component or accessory; not otherwise specified

Example wheelchair and accessory codesHCPCSCovered

E1234	Wheelchair, pediatric size, tilt-in-space; folding; adjustable without seating system
E2231	Manual wheelchair accessory; solid seat support base
E1225	Wheelchair accessory, manual semi-reclining back
E0951	Heel
K0038	Leg strap, each

Respiratory equipmentHCPCSCovered

E1390	Oxygen concentrator, single delivery port
E0430	Portable gaseous oxygen system, purchase
E0445	Oximeter device for measuring blood oxygen levels noninvasively
E0465	Home ventilator, any type

CPAP and related accessoriesHCPCSCovered

E0601	Continuous airway pressure (CPAP) device
E0562	Humidifier, heated, used with positive airway pressure device
E2599	Accessory for speech generating device, not otherwise classified

Selected respiratory DME (approved)HCPCSCovered

E1390	Oxygen concentrator, single delivery port
E0430	Portable gaseous oxygen system, purchase includes regulator, flowmeter, humidifier, cannula or mask, and tubing
E0445	Oximeter device for measuring blood oxygen levels noninvasively

Pediatric wheelchair components (approved)HCPCSCovered

E2293	Back, contoured, for pediatric size wheelchair including fixed attaching hardware
E2292	Seat, planar, for pediatric size wheelchair including fixed attaching hardware
E1234	Wheelchair; pediatric size, tilt-in-space; folding; adjustable, without seating system

Enteral nutrition (approved)HCPCSCovered

B4160	Enteral formula; for pediatrics nutritionally complete calorically dense (>=0.7 kcal/ml)
B9002	Enteral nutrition infusion pump

Covered DME codes (excerpt)HCPCSCovered

E2510	Speech generating device, synthesized speech
E2293	Back, contoured, for pediatric size wheelchair including fixed attaching hardware
E0445	Oximeter device for measuring blood oxygen levels noninvasively
E1390	Oxygen concentrator, single delivery port
E0430	Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask; and tubing
E1237	Wheelchair, pediatric size, rigid, adjustable, without seating system
K0108	Wheelchair component or accessory; not otherwise specified

Referenced DME/HCPCS codesHCPCSCovered

E0430	Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula mask, and tubing
E1390	Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate
E0445	Oximeter device for measuring blood oxygen levels noninvasively
E0465	Home ventilator, any type; used with invasive interface (e.g., tracheostomy tube)
E1028	Wheelchair accessory, manual swingaway; retractable or removable mounting hardware
K0108	Wheelchair component or accessory; not otherwise specified
B9998	NOC for enteral supplies
B9002	Enteral nutrition infusion pump with alarm
T4532	Pediatric sized disposable incontinence product; protective underwear/pull-on

Selected DME/HCPCS codesHCPCSCovered

E1390	Oxygen concentrator, single delivery port, capable of delivering ≥85% concentration at prescribed flow rate
E0430	Portable gaseous oxygen system, purchase (includes regulator, flowmeter, humidifier, cannula or mask, and tubing)
E0445	Oximeter device for measuring blood oxygen levels noninvasively
E0465	Home ventilator, any type, used with invasive interface
E0431	Portable gaseous oxygen system, rental

Selected CPT codes (hospital/acute care)CPTCovered

95810	Polysomnography; age years or older, sleep staging with attended technologist
95811	Polysomnography with initiation of CPAP or bilevel
93458	Catheter placement in coronary artery(ies) for coronary angiography
43239	Upper GI endoscopy with biopsy

PolysomnographyCPTCovered

95810	Polysomnography; adult, attended by technologist
95811	Polysomnography with initiation of CPAP or bilevel

Dermatologic destruction codesCPTCovered

17106	Destruction of cutaneous vascular proliferative lesions; <10 sq cm
17107	Destruction of cutaneous vascular proliferative lesions; 10-50 sq cm

Knee arthroscopyCPTCovered

29877	Knee arthroscopy; chondroplasty
29874	Knee arthroscopy; removal of loose body

Ophthalmic procedures and imagingCPTCovered

67311	Strabismus surgery; horizontal muscle (recession or resection)
C973322	Non-ophthalmic fluorescent vascular angiography

Sleep study and ENT proceduresCPTCovered

95810	Polysomnography; with sleep staging attended by technologist
42820	Tonsillectomy and adenoidectomy; younger than age 12

Selected CPT/HCPCS codes appearingCPT

97530	Therapeutic activities, direct (one-on-one) patient contact, each 15 minutes
97032	Application of modality to one or more areas; electrical stimulation (manual); each 15 minutes
97035	Application of modality to one or more areas; ultrasound, each 15 minutes
97112	Therapeutic procedure each 15 minutes; neuromuscular reeducation
97110	Therapeutic exercises each 15 minutes
97140	Manual therapy techniques, each 15 minutes
97116	Therapeutic procedure each 15 minutes; gait training
95810	Polysomnography; sleep staging with technologist
42820	Tonsillectomy and adenoidectomy; younger than age 12
42821	Tonsillectomy and adenoidectomy; age 12 or over

Sample sleep study and chemodenervation codesCPTCovered

95810	Polysomnography; age years or older; sleep staging with additional parameters, attended by technologist
95811	Polysomnography; with initiation of CPAP/BiPAP
64643	Chemodenervation of one extremity
64733	Obstructive sleep apnea (adult) (ICD referenced in text)

Miscellaneous surgical codesCPTCovered

41899	Unlisted procedure, dentoalveolar structures
11441	Excision other benign lesion including margins, face/ear/eyelid/nose/lip; 0.6–1.0 cm

Behavioral health and therapy codesCPTCovered

90834	Psychotherapy, 45 minutes with patient
90837	Psychotherapy, 60 minutes with patient
90791	Psychiatric diagnostic evaluation
90792	Psychiatric diagnostic evaluation with medical services
92507	Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
97530	Therapeutic activities, direct (one-on-one) patient contact, each 15 minutes
97110	Therapeutic procedure; therapeutic exercises, each 15 minutes

Listed covered procedure codes (Medicaid, outpatient behavioral health and related therapies)CPTCovered

90832	Psychotherapy, 30 minutes with patient
90834	Psychotherapy, 45 minutes with patient
90837	Psychotherapy, 60 minutes with patient
90791	Psychiatric diagnostic evaluation
97530	Therapeutic activities, direct (one-on-one), each 15 minutes
97110	Therapeutic procedure; therapeutic exercises, each 15 minutes
92507	Treatment of speech, language, voice, communication; individual

Referenced procedure codesCPT | HCPCS | mixedCovered

T1019	Personal care services, per 15 minutes
T1019U3	Personal care services, per 15 minutes (modifier/U3 variant present in document)
90832	Psychotherapy, 30 minutes with patient
90834	Psychotherapy, 45 minutes with patient
90837	Psychotherapy, 60 minutes with patient

Medicaid personal care and related equipment codesHCPCSCovered

T1019	Personal care services, per 15 minutes
T1019U3	Personal care services, per 15 minutes (Medicaid variant/modifier noted)
E1390	Oxygen concentrator, single delivery port

Enteral formula caloric density — pediatric threshold

Pediatric caloric density threshold>= 0.7 kcal/ml (enteral formula for pediatrics)

Related enteral supply codeB4160 (Enteral formula; pediatric, nutritionally complete, calorically dense)

Provider Actions, Authorization and Billing Notes

Prior Authorization

Approval indications for DME items

Prior authorization and approval indications for DME and wheelchair components: Many wheelchair accessories and pediatric seating items (examples: E0973 adjustable-height detachable armrest; E0971 anti-tipping device; E2607 skin protection/positioning wheelchair seat cushion; E2293 contoured pediatric back; E1237 pediatric rigid adjustable wheelchair) are marked Approved for Medicaid when associated clinical diagnoses (e.g., cerebral palsy, hypermobility syndrome, developmental disorders) are documented. Providers must confirm member-specific approvals and ensure supportive diagnosis and justification are on file.

E0973 Wheelchair accessory; adjustable height; detachable armrest — Approved
E0971 Manual wheelchair accessory; anti-tipping device — Approved
E2607 Skin protection and positioning wheelchair seat cushion (<22") — Approved
E2293 Contoured pediatric wheelchair back — Approved
E1237 Wheelchair, pediatric size, rigid, adjustable — Approved

Prior Authorization

Respiratory equipment approvals

Definitions and Key Terms

Program name used throughout (PASSE)

Program namePASSE (Provider-led Arkansas Shared Savings Enterprise)

Payer contextReferenced throughout in relation to Medicaid DME and service approvals

Document scopeUsed as the program identifier for listed approvals and coverage decisions

Diagnosis code referenced as 'Cerebral palsy, unspecified' (G809 / 6809)

Diagnosis labelCerebral palsy, unspecified

ICD codes shownG809 / 6809 referenced as 'Cerebral palsy, unspecified' in multiple entries

Policy Summary

PayerCareSource

PolicyDurable Medical Equipment and Wheelchair Accessories for Medicaid (PASSE)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionFor listed DME and wheelchair accessories, billers/providers should follow documented approval decisions (items shown as Approved for Medicaid PASSE members).

SourceLink

On This Page

Associated equipmentB9002 (Enteral nutrition infusion pump) referenced with enteral formulas

Oxygen concentrator oxygen concentration

Required oxygen concentrationCapable of delivering 85% or greater oxygen concentration at the prescribed flow rate

Representative concentrator codeE1390 (Oxygen concentrator, single delivery port)

Related portable systemE0430 (Portable gaseous oxygen system, purchase) referenced alongside concentrator

Oxygen concentrator capability (E1390)

E1390 capabilityOxygen concentrator, single delivery port capable of delivering ≥85% oxygen at prescribed flow rate (E1390)

Use contextListed as Approved for members with chronic respiratory failure, tracheostomy status, and related diagnoses

Associated devicesE0430 portable gaseous oxygen system and E0445 oximeter commonly listed with E1390

Oxygen concentrator performance (general)

Performance requirementCapable of delivering 85% or greater oxygen concentration at the prescribed flow rate

Related respiratory equipmentHome ventilator (E0465), respiratory suction pump, and oximeter (E0445) appear in same approval entries

Approval statusDevices meeting this performance description are listed as 'Approved' in Medicaid PASSE entries

Oxygen concentrator performance (redundant reference)

Restated performance specCapable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate

Documented examplesE1390 and E0430 repeatedly shown together in Approved listings for respiratory diagnoses

Measurement contextListed in DME approval tables tied to diagnoses such as chronic respiratory failure and obstructive sleep apnea

Therapy time unit (15 minutes for CPT codes)

Therapy billing unitEach 15 minutes (per CPT descriptors such as 97110, 97530, 97112)

Representative CPTs97110, 97530, 97112 listed with per-15-minute units

Use casesApplied to therapeutic exercises, therapeutic activities, neuromuscular reeducation in Approved entries

Time unit (15 minutes for many therapy CPT codes)

Standard time unit15 minutes (for many therapy CPT codes)

Examples in document97530, 97110, 97112 and other therapy/modality codes described as per 15 minutes

Approval contextTherapy codes billed in 15-minute units are shown as Approved in Hospital/Acute Care and Outpt settings

OPAS unit indicator (999 units)

OPAS unit indicator999 units (OPAS - Outpatient Ambulatory Services)

Setting labelOPAS = Outpatient Ambulatory Services; 999 units shown in multiple Approved lines

Approval noteEntries using OPAS list 999 units alongside Approved status and Hospital/Acute Care designation

OPAS unit placeholder (999 units repeated)

OPAS placeholder999 units (repeated as unit placeholder in OPAS entries)

Interpretation999 appears as the unit field for OPAS entries in the document (likely a standardized placeholder)

Associated entriesUsed across multiple diagnosis-to-procedure OPAS rows marked Approved

Visit authorization (Office Visit, Practitioner) — placeholder reference

Visit authorization fieldOffice Visit; Practitioner (Indicate number of visits authorized) appears as the visit authorization placeholder

Usage contextAssociated with psychotherapy and behavioral health entries (e.g., 90832/90834/90837) in Outpt Behav Hlth Agency

Detail limitationSpecific visit counts are not present in the excerpt — the field indicates where authorized visit counts would be recorded

billing_unit — per 15 minutes for personal care services

Billing unit for personal carePer 15 minutes for personal care services (T1019 / T1019U3)

Service exclusionsNot payable for inpatients or residents of hospital, nursing facility, ICF/MR or IMD

Documentation requirementMust be part of the individualized plan of treatment when billed

Respiratory equipment approvals: Home ventilators (E0465 and EO465UB variants), oxygen concentrators (E1390), portable gaseous oxygen systems (E0430), CPAP devices (E0601), humidifiers for PAP (E0562), and respiratory suction pumps are listed as Approved for Medicaid where clinical indications (e.g., chronic respiratory failure, tracheostomy/ventilator dependence, obstructive sleep apnea) are present. Verify device-specific coverage and any ambulatory/hospital setting distinctions.

E0465 Home ventilator (used with invasive interface/tracheostomy) — Approved
EO465UB Home ventilator (UB variant) — Approved
E1390 Oxygen concentrator, single delivery — Approved
E0430 Portable gaseous oxygen system (purchase) — Approved
E0601 CPAP device — Approved
E0562 Heated humidifier for PAP — Approved

Note

Approval status summary

Approval status summary: The excerpts show many DME, respiratory, wheelchair components, and therapy services labeled as Approved for Medicaid. Where listed as Approved, providers should still confirm member eligibility, service location (e.g., Hospital/Acute Care vs Outpatient), and any program-specific pathways (PASSE vs standard Medicaid).

Multiple items across DME and therapy categories marked Approved for Medicaid in these excerpts
Some services specify setting (e.g., Hospital/Acute Care, Outpt Behav Hlth Agency, OPAS 999 units) — confirm correct place of service
No explicit prior authorization steps are shown in every line; however, individual program rules (PASSE) or device-specific processes may apply

Prior Authorization

Prior authorization / approved DME list (excerpt)

Prior authorization / approved DME list (excerpt): Speech generating devices (E2510), accessories (E2599, E2512), pediatric contoured seating (E2293), multiple wheelchair accessories (E0950 tray, E1028 swingaway hardware, E2213 mounting hardware), and technician labor for complex repairs (K0739) appear in approved listings. Providers must reference the member’s approved items and the specific HCPCS when ordering or billing.

E2510 Speech generating device, synthesized speech — Approved
E2599 Accessory for speech generating device — Approved
E2512 Accessory for speech generating device, mounting system — Approved
E2293 Contoured pediatric wheelchair seating — Approved
E0950 Wheelchair tray — Approved
E1028 Manual swingaway mounting hardware — Approved
K0739 Repair/nonroutine DME service (technician labor, per 15 min) — listed

Prior Authorization

Prior authorization / approval listing (Medicaid PASSE DME)

Prior authorization / approval listing (Medicaid PASSE DME excerpt): PASSE listings show pediatric wheelchair components, speech device accessories, portable oxygen systems, and other DME flagged as Approved under Medicaid PASSE arrangements. Providers serving PASSE members should follow PASSE-specific authorization workflows and document diagnosis linkage (e.g., cerebral palsy, Down syndrome, developmental disorders).

Pediatric wheelchair components (E2293, E1237, E1028) — Approved under PASSE entries
Speech generating devices and accessories (E2510, E2599, E2512) — Approved
E0430 Portable gaseous oxygen system — Approved
Diagnosis linkages (e.g., G800/G809 cerebral palsy, Q909 Down syndrome) appear in PASSE rows

Prior Authorization

DME approvals (excerpt)

DME approvals (excerpt): Examples across excerpts include hospital beds (E0260 semi-electric with mattress), enteral supplies, humidifiers, oximeters (E0445), home ventilators, suction pumps, and miscellaneous DME (E1399, E1390). Each approved item should be ordered using the correct HCPCS and supported by clinical documentation.

E0260 Hospital bed, semi-electric with mattress and rails — Approved
B4152 Enteral formula (calorically dense) — Approved
E0445 Oximeter device — Approved
E1399 Durable medical equipment, miscellaneous — Approved
E1390 Oxygen concentrator — Approved

Billing Rule

Therapy services — authorization hints

Therapy services — authorization hints: Physical and occupational therapy procedures (97110, 97112, 97110 for strength/endurance, 97530 therapeutic activities, 97112 neuromuscular reeducation, 97110 therapeutic exercise) are listed as Approved with references to 15-minute units and visit counts. Providers should request authorizations indicating number of visits/units and link to functional diagnoses (e.g., muscle weakness, post-fracture).

97110 Therapeutic exercises, each 15 minutes — Approved
97530 Therapeutic activities, each 15 minutes — Approved
97112 Neuromuscular reeducation, each 15 minutes — Approved
Authorization requests should specify number of visits or units and supporting diagnosis

Documentation Required

Sleep study services

Sleep study services: Polysomnography codes (95810, 95811) are listed as Approved when attended by a technologist and may have setting designations (Hospital/Acute Care). CPAP (E0601) and related devices are also Approved for obstructive sleep apnea indications. Ensure documentation of attended studies and diagnostic criteria for device coverage.

95810 Polysomnography; age ≥ 6 years; sleep staging with technologist — Approved
95811 Polysomnography with initiation of CPAP/BiPAP — Approved
E0601 CPAP device — Approved
Document technologist attendance and clinical diagnosis (e.g., obstructive sleep apnea)

Prior Authorization

Facet Joint Injections (with image guidance)

Facet joint injections with image guidance: Cervical and other facet (zygapophyseal) joint injections with image guidance (CPT 64490, 64491 and related codes) are listed as Approved and designated for Hospital/Acute Care in these excerpts. Confirm indication (e.g., spondylosis, radiculopathy) and appropriate image guidance documentation.

64490 Paravertebral facet injection with image guidance — Approved; Hospital/Acute Care
64491 Paravertebral facet injection with image guidance (cervical) — Approved; Hospital/Acute Care
Include image guidance documentation and relevant ICD-10 diagnosis (e.g., M47812 spondylosis)

Note

Procedure approvals (sample)

Procedure approvals (sample): Several procedure-to-diagnosis pairings are marked Approved and include setting notes (Hospital/Acute Care, OPAS). Examples include outpatient ambulatory services (OPAS 999 units) approvals and common procedure codes with approved status. Providers should verify place-of-service and authorization for OPAS-coded episodes.

OPAS Outpatient Ambulatory Services (999 units) — Approved in multiple entries
Examples of approved procedural listings include diagnostic laparoscopy and other surgical/anesthesia-coded items with Hospital/Acute Care designation
Confirm OPAS authorization thresholds and setting-specific requirements before scheduling procedures

Prior Authorization

Approved outpatient psychotherapy and evaluation services (Medicaid)

Approved outpatient psychotherapy and evaluation services (Medicaid): Behavioral health CPT codes (90832, 90834, 90837 and their U4 variations) and office visit authorizations are listed as Approved for Outpt Behav Hlth Agency. Authorizations should specify number of visits and be tied to behavioral health diagnoses (e.g., major depressive disorder, PTSD, ADHD).

90832 Psychotherapy, 30 minutes — Approved for Outpt Behav Hlth Agency
90834 Psychotherapy, 45 minutes — Approved for Outpt Behav Hlth Agency
90837 Psychotherapy, 60 minutes — Approved for Outpt Behav Hlth Agency
Office Visit (OV) authorizations may be used to indicate number of visits authorized

Billing Rule

Rehabilitative and speech/OT services (Medicaid)

Rehabilitative and speech/OT services (Medicaid): Speech therapy (92507), therapeutic activities (97530), and other rehabilitative codes are listed as Approved for Outpt Behav Hlth Agency when matched with appropriate developmental or functional diagnoses. Providers must document therapy goals and unit-level billing (15-minute increments where applicable).

92507 Speech therapy treatment — Approved for Outpt Behav Hlth Agency
97530 Therapeutic activities, direct (one-on-one), each 15 minutes — Approved
97110, 97112 and related PT/OT codes — Approved when supported by diagnosis and goals

Prior Authorization

Psychotherapy Authorization

Psychotherapy Authorization: For behavioral health diagnoses, psychotherapy CPT codes (90832/90834/90837) and visit-based authorizations are consistently shown as Approved. Providers should request authorizations listing the specific CPT code(s), number of sessions, session length, and diagnosis; use U4 modifiers or program-specific fields when indicated.

Request authorizations that specify: CPT code (90832/90834/90837), session length, number of visits, and diagnosis
Use Outpt Behav Hlth Agency routing for Medicaid behavioral health services
Ensure documentation supports medical necessity for the authorized number of sessions

Associated approvals

Frequently paired with wheelchair components/accessories and marked Approved

Durable Medical Equipment (DME) — Medicaid coverage summary

DME coverage summaryDurable Medical Equipment items listed are shown as Approved for Medicaid PASSE when paired with listed diagnoses

Included item typesWheelchairs, wheelchair accessories, respiratory equipment, enteral supplies, and related DME

Provider specialtyDurable Medical Equipment specialty listed as requester/provider for these items

Durable Medical Equipment (DME) — term reference

Term: DMEDurable Medical Equipment (DME)

Typical examplesWheelchair components/accessories, oxygen equipment, enteral pumps and formulas

Coverage implicationItems documented as DME are frequently marked Approved under Medicaid PASSE entries

Wheelchair accessory HCPCS codes (E0xxx) reference

Wheelchair accessory HCPCS seriesHCPCS codes beginning with 'E0xxx' used for wheelchair accessories (e.g., E2293, E2231, E1028)

Pediatric focusMultiple E0xxx codes reference pediatric wheelchair components (contoured backs, seats, tilt-in-space frames)

Coverage statusThese E0xxx accessory codes are shown as Approved for relevant diagnoses

Approval status indicating Medicaid coverage ('Approved')

Approval indicator'Approved' denotes Medicaid coverage for the listed item or service

Prevalence'Approved' appears repeatedly throughout DME, therapy, and behavioral health entries

Implication for billingLines marked 'Approved' indicate coverage subject to documented criteria in the excerpt

Calorically dense enteral formula (pediatric threshold noted)

Calorically dense formula threshold>= 0.7 kcal/ml specified for pediatric enteral formula (B4160)

Code exampleB4160 Enteral formula; pediatric nutritionally complete, calorically dense (>=0.7 kcal/ml)

Associated suppliesB9998 NOC for enteral supplies and B9002 enteral infusion pump referenced alongside formulas

Oxygen concentrator, single delivery port, performance spec (E1390)

E1390 descriptionOxygen concentrator, single delivery port — capable of delivering ≥85% oxygen at prescribed flow

Performance standard≥85% oxygen concentration at prescribed flow rate cited as the specification for concentrators

Associated approvalsE1390 appears in multiple Approved DME listings for respiratory diagnoses

Speech generating device (E2510) — described

E2510 descriptionSpeech generating device, synthesized speech permitting multiple methods of message formulation and device access (E2510)

AccessoriesE2599 and E2512 accessories and mounting systems referenced alongside E2510

Approval contextE2510 shown as Approved for developmental and communication disorder diagnoses

PASSE / Medicaid program references

Program referencePASSE program references throughout the document in relation to Medicaid approvals

Payer linkageUsed as the program/payer context for listed DME and service approvals

Document scopePASSE entries enumerate Approved items and services under Medicaid

'Approved' definition — coverage indication

'Approved' definitionIndicates the item or service line is authorized for Medicaid coverage in the documented entries

Usage frequencyThe term 'Approved' is applied broadly across DME, therapy, and behavioral health rows

ImplicationProviders can interpret 'Approved' lines as covered when associated criteria/diagnoses are met

Durable Medical Equipment (DME) term (redundant)

DME termDurable Medical Equipment (DME)

ExamplesIncludes oxygen equipment, wheelchairs, wheelchair accessories, enteral pumps and supplies

Coverage contextDME items shown in PASSE/Madicaid tables are frequently marked Approved

Oxygen concentrator specification (≥85% at prescribed flow)

Concentrator performance specOxygen concentrator must be capable of delivering ≥85% oxygen at the prescribed flow rate

Documentation examplesE1390 is repeatedly documented with this performance requirement across entries

Associated equipmentPortable systems (E0430) and oximeters (E0445) are listed in the same respiratory approval rows

'attended by technologist' — polysomnography note

'Attended by technologist' noteApplied to polysomnography services indicating technologist presence during sleep study (e.g., 95810/95811)

SettingPolysomnography codes are shown Approved in Hospital/Acute Care setting

Associated codes95810, 95811 referenced with attended technologist and approval

Therapeutic activities (97530) definition — 15-minute unit

97530 unit definitionTherapeutic activities (97530) billed as each 15 minutes (direct, one-on-one patient contact)

PurposeUse of dynamic activities to improve functional performance; one-on-one contact emphasized

Related therapy codes97530 appears alongside 97110 and 97112 in Approved therapy entries

Care setting where listed procedures are approved (Hospital/ Acute Care)

Care settingHospital/ Acute Care (setting noted for many Approved procedures)

ExamplesPolysomnography, therapy services, and select surgical procedures listed with Hospital/Acute Care designation

ImplicationCoverage and setting together indicate where service reimbursement is authorized in the excerpt

Authorization status indicated for listed codes in this fragment ('Approved')

Approval status used'Approved' indicates listed codes are authorized for Medicaid in the excerpt

ScopeApplied across DME, CPT, and behavioral health code listings

Practical noteLines marked 'Approved' should be interpreted as covered when other listed criteria are met

Approval status indicating coverage for Medicaid in listed setting ('Approved')

Coverage indicator'Approved' shown as coverage status for multiple entries tied to Medicaid

Setting linkageApproval entries often include the care setting (e.g., Hospital/Acute Care)

Repetition'Approved' appears throughout the DME and service tables in the document excerpt

Care setting specified for the approved procedure (Hospital/ Acute Care)

Specified care settingHospital/ Acute Care specified for many Approved procedure entries

Typical proceduresTherapy CPTs and polysomnography are examples shown with this setting

Billing implicationIndicates the facility/place of service where authorization applies in the excerpt

Outpatient Ambulatory Services (OPAS) term

OPAS termOPAS = Outpatient Ambulatory Services

Unit notationOPAS entries in the document frequently show 999 units

Use in listingsOPAS used for outpatient procedure/service rows marked Approved

OPAS (Outpatient Ambulatory Services) — redundant reference

OPAS abbreviationOPAS (Outpatient Ambulatory Services)

Document patternAppears repeatedly as OPAS with 999 units and Approved status in multiple rows

Setting relationOften paired with Hospital/Acute Care designation in entries

Outpt Behav Hlth Agency — service setting definition

Outpt Behav Hlth Agency termOutpt Behav Hlth Agency = Outpatient Behavioral Health Agency

Associated servicesPsychotherapy (90832/90834/90837), psychiatric diagnostic evaluations (90791/90792), and therapy CPTs listed under this setting

Approval contextThese codes are shown as Approved for listed behavioral health diagnoses under Medicaid

Outpt Behav Hlth Agency — redundant

Outpatient Behavioral Health AgencyOutpt Behav Hlth Agency (service setting used for behavioral health approvals)

Common codes90832/90834/90837 psychotherapy codes and 90791/90792 evaluations referenced under this setting

Coverage noteEntries show these services as Approved for Medicaid when paired with listed diagnoses

'Approved' — redundant coverage indicator

'Approved' meaningIndicates the service/code pairing is authorized for Medicaid in the excerpt

ApplicationUsed across behavioral health and therapy code listings

Provider implicationProviders can treat 'Approved' rows as covered when criteria and setting align

Personal care services (T1019) — definition and unit

Personal care billing unitT1019 billed per 15 minutes

Not payable settingsNot payable for inpatients or residents of hospital, nursing facility, ICF/MR or IMD

Plan requirementMust be part of the individualized plan of treatment to be Approved

Psychotherapy CPT codes mapping to session lengths

Psychotherapy session mappingPsychotherapy CPTs map to session lengths (90832=30 min, 90834=45 min, 90837=60 min)

Behavioral health placementThese psychotherapy codes are shown Approved in Outpt Behav Hlth Agency entries

Authorization placeholderOffice Visit; Practitioner field used to indicate number of visits authorized in some rows

Personal Care (T1019 / T1019U3) billing and exclusion note

Personal Care billing noteT1019 / T1019U3 billed per 15 minutes; must be part of individualized plan and not payable for inpatient/resident settings

Modifier variantT1019U3 appears as a Medicaid variant/modifier for personal care in the excerpt

Coverage examplesPersonal care services are listed Approved for diagnoses such as cerebral palsy, epilepsy, COPD, and intellectual disabilities