Medical Equipment, Device, and Supplies (MEDS) Coverage and Prior Authorization Grid
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Governance of coverage, prior authorization requirements, and benefit limits for Durable Medical Equipment (DME), supplies, prosthetics/orthotics, diabetic supplies, nutritional formulas, oxygen, hearing aids, and related MEDS services for HUSKY Health members.
No material clinical or coverage changes in this revision.
Coverage, Limits, and Medical Necessity
inv-01: General DME Coverage
Coverage summaries by program tier
See DSS MEDS - DME fee schedule and huskyhealthct.org/providers for details.
Effective July 1, 2025: 100% covered statement referenced in provider grid.
See DSS MEDS - DME fee schedule and huskyhealthct.org/providers for details.
inv-02: Motorized Wheelchair Coverage Limit
Motorized wheelchair coverage (HUSKY B)
Prior authorization (PA) is required for motorized wheelchairs under the HUSKY B program; see DSS fee schedule and provider page for PA submission guidance.
inv-03: Orthopedic/Diabetic Shoes
Orthopedic/Diabetic shoe coverage
Any exceptions to this limit require prior authorization (PA). PA is not required for shoe modifications and additions; refer to DSS Orthotic and Prosthetic Fee Schedule for documentation requirements and PA guidance.
inv-04: Nutritional Formulas
Nutritional formulas and specialized foods
Specialized foods for inherited metabolic disease (e.g., PKU; HCPCS code S9435) require prior authorization and are covered under the medical benefit when PA is approved.
inv-05: Oxygen Systems
Oxygen rental coverage
The 'as‑needed' (PRN) use of oxygen is not covered.
Coverage exclusions and network requirements apply across HUSKY programs. Out-of-network services are not covered unless the provider is an enrolled CMAP provider, per program rules. Providers must follow enrollment requirements to be reimbursed for services delivered to HUSKY members.
Certain items and billing situations may trigger denials if requirements are not met. Services for which prior authorization (PA) is required but not obtained, services that are not medically necessary, services beyond the practitioner’s scope of practice, and services beyond what is necessary are listed as general exclusion risks and may be denied.
Services that are not medically necessary are excluded and subject to denial. The policy identifies several general denial risks including: failure to obtain required PA, provision of services not within the practitioner’s scope under state law, and services or items for which the provider does not usually charge.
Providers should verify medical necessity and obtain all required prior authorizations before billing to avoid claim denials under these exclusions.
Relevant HCPCS/CPT/ICD Codes
| S9435 | specialized foods for inherited metabolic disease (e.g., PKU) |
Prior Authorization, Documentation, and Billing Actions
Obtain prior authorization for many DME/MEDS items
Prior authorization (PA) is required for a variety of DME items, many prosthetic and orthotic devices, specialized food formulas (e.g., S9435), and rental of stationary gaseous or liquid oxygen systems in long‑term care facilities; refer to the DSS MEDS DME fee schedule for full listing and submission instructions.
- PA required for a variety of DME items per DSS MEDS - DME fee schedule
- PA required for specialized foods for inherited metabolic disease (example: code S9435)
- PA required for rental of stationary gaseous or liquid oxygen systems in LTC settings
PA required for motorized wheelchairs (HUSKY B)
Motorized wheelchairs for HUSKY B members require prior authorization; coverage is limited to one motorized wheelchair every five years.
- PA required for motorized wheelchairs under HUSKY B
- Coverage limited to 1 motorized wheelchair per 5 years
Request PA for exceptions to shoe limits
Any request that exceeds the two‑pair per calendar year limit for orthopedic/diabetic shoes (members 21+) must be submitted with prior authorization; shoe modifications and additions do not require PA.
- Orthopedic/diabetic shoes limited to two pairs per calendar year for members 21+
- Exceptions to this limit require PA
- Shoe modifications and additions do not require PA
Follow Medicaid Preferred Product List for diabetic supplies
Diabetic supplies may be obtained via pharmacy or DME depending on member age; pharmacy claims for diabetic supplies (under age 21 and for certain supplies for ages 21+) are subject to the Medicaid Preferred Product List—consult the Diabetic Supplies Preferred Product List on the CT Medical Assistance Program website.
- Members under 21: diabetic supplies can be billed to pharmacy or medical; pharmacy claims for <21 are subject to the Medicaid Preferred Product List (effective Nov 4, 2020)
- Members 21+: certain diabetic supplies are covered under medical DME but many supplies are on the pharmacy Preferred Product List—see the preferred list at www.ctdssmap.com
Include required ICD‑10‑CM code on pharmacy claims for nutritional formulas (21+)
For pharmacy claims for nutritional supplements for members age 21 and older, include an appropriate ICD‑10‑CM diagnosis code from the DSS list on the claim/prescription; see Provider Manuals Chapter 8, Section 8.5 on the CT Medical Assistance Program site for the diagnosis code list.
- Pharmacy claims for members 21+ require one of the specified ICD‑10‑CM diagnosis codes on the claim
- Diagnosis code list located in Provider Manuals Chapter 8 → Section 8.5 at www.ctdssmap.com
Submit PA with DSS fee‑schedule documentation for prosthetics/orthotics
When submitting PA for prosthetic and orthotic devices, include supporting documentation in accordance with the DSS Orthotic and Prosthetic Fee Schedule and follow documentation guidance on the HUSKY provider page.
- Reference the DSS Orthotic and Prosthetic Fee Schedule for items requiring PA
- Follow supporting documentation instructions on the HUSKY Health provider page (huskyhealthct.org/providers)
Verify PA and medical necessity to avoid denials
Claims or services for which PA is required but not obtained, services deemed not medically necessary, services beyond the provider’s scope of practice, or items the provider does not usually charge for are subject to denial; verify PA and medical necessity before submitting.
- Services lacking required PA may be denied
- Services not medically necessary may be denied
- Services outside practitioner scope or beyond necessary treatment may be denied
Do not bill 'as‑needed' oxygen—it's not covered
Do not bill or request coverage for oxygen provided "as‑needed" (PRN); 'as‑needed' oxygen use is not covered and may result in denial when billed as a covered service.
- 'As‑needed' (PRN) oxygen use is not covered and may be denied
- PA is required for rental of stationary gaseous or liquid oxygen systems in LTC settings (purchase included in LTC per diem may avoid PA)
Medical Necessity Criteria
inv-20: Nutritional Formula Necessity
General coverage exclusions and denial risks summarized
See oxygen rental rules for LTC rental PA exceptions.
Providers should verify network enrollment status prior to billing.
Coverage varies by program tier; refer to provider grid.
Obtain PA when required to reduce risk of denial.
Rental, Purchase, and Capitation Rules
| Equipment | Rule | Notes |
|---|---|---|
| Stationary gaseous or liquid oxygen systems | rental | PA is required only for rental of stationary gaseous or liquid oxygen systems in long-term care (LTC) facilities; if an LTC facility purchases the systems and includes the cost in the per diem rate calculation, prior authorization is not required. 'As‑needed' (PRN) use of oxygen is not covered. |
| Equipment | Rule | Notes |
|---|---|---|
| Motorized wheelchairs | capped_rental | Coverage limited to one motorized wheelchair every five years for HUSKY B members; prior authorization is required under the HUSKY B program. |
Replacement Frequency and Limits
Documentation Requirements for Claims and Authorization
Add required ICD-10-CM code for nutritional supplements (age 21+)
Include an appropriate ICD-10-CM diagnosis code on the claim or prescription for nutritional supplements for members age 21 and older per the DSS Provider Manuals (see Pharmacy, Section 8.5).
Provide DSS fee‑schedule supporting documentation with PA requests
Provide the supporting documentation specified in the DSS Orthotic and Prosthetic Fee Schedule when submitting a prior authorization request for prosthetic or orthotic items and consult the HUSKY provider page for item-specific requirements.
Policy Purpose and Scope
This document is an administrative benefits and prior authorization grid and is not a clinical treatment guideline. It summarizes coverage categories, benefit limits, and prior authorization requirements for Durable Medical Equipment (DME), supplies, prosthetics/orthotics, nutritional formulas, oxygen systems, and related MEDS services across HUSKY A, B, C, and D programs.
Use this grid to determine benefit applicability and PA requirements; for clinical decision-making and complete coding details refer to the DSS fee schedules and HUSKY provider resources referenced elsewhere in the policy.
Exclusions and Non-Covered Services
Items not covered under the MEDS grid include the 'as-needed' (PRN) use of oxygen; claims for PRN oxygen may be denied. Stationary gaseous or liquid oxygen rentals in long-term care have specific PA rules, but PRN oxygen use remains not covered.
Orthopedic shoes are generally not covered except where specific diabetic shoe HCPCS codes apply (see coding section for A5500–A5513); diabetic/orthopedic shoes for members age 21 and older are limited to two pairs per calendar year, and exceptions to limits require PA.
Wigs and hairpieces are not covered for certain programs (for example, not covered for HUSKY B). Additionally, out-of-network services are not covered unless the provider is an enrolled CMAP provider.
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