CurrentMississippi Division of MedicaidPolicy N/A

Covered Medical Supplies (Rule 2.2)

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Defines Mississippi Division of Medicaid coverage, medical necessity criteria, documentation, quantity limits, and provider obligations for medical supplies and certain DME-related supplies for beneficiaries.

Policy Summary

PayerMississippi Division of Medicaid

PolicyCovered Medical Supplies (Rule 2.2)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Last ReviewJan 1, 2025

Next Review DateN/A

Key ActionObtain and maintain a physician-signed Certificate of Medical Necessity (CMN) and renew every 6 months (12 months for chronic cases).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6max incontinence garments/day (age 3+)

400 / 200 / 2monthly limits: wipes / gloves / skin protectant

6 mo / 12 moCMN renewal interval

BundleCGM billing requirement

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CurrentMississippi Division of MedicaidPolicy N/A

Covered Medical Supplies (Rule 2.2)

Customize your policy alerts

Sign up for all Mississippi Division of Medicaid policy alerts

Know when Mississippi Division of Medicaid releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerMississippi Division of Medicaid

PolicyCovered Medical Supplies (Rule 2.2)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Last ReviewJan 1, 2025

Next Review DateN/A

Key ActionObtain and maintain a physician-signed Certificate of Medical Necessity (CMN) and renew every 6 months (12 months for chronic cases).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6max incontinence garments/day (age 3+)

400 / 200 / 2monthly limits: wipes / gloves / skin protectant

6 mo / 12 moCMN renewal interval

BundleCGM billing requirement

max supply per delivery (incontinence)

Covered Supplies and Criteria

General covered supplies

Covered when supplies are medically necessary, considered standard care for treatment of the beneficiary's medical condition, and dispensed in quantities that meet medical needs without excessive utilization.

General coverage condition: Supply is medically necessary and considered standard care for treatment and dispensed in quantities that meet the beneficiary's medical needs without excessive utilization

Lead-in general rule from Rule 2.2

CGM supplies

Continuous Glucose Monitoring (CGM) supplies

CGM bundle requirement: Supply allowance covers disposable sensors and transmitter as a bundle; supplies billed separately will not be covered

DME receiver coverage and non-DME device exclusion specified in Rule 2.2

DME receiver rule: A DME receiver to display glucose data is covered if used alone or in conjunction with a non‑DME device; non‑DME devices will not be covered as the DME receiver, and if a DME receiver is never used the supply allowance will not be covered

See receiver and non‑DME device provisions

Elbow and heel protectors

Elbow/heel protector criteria: Beneficiary is bed/chair confined and has history of decubitus ulcers on a heel or elbow OR beneficiary is bed/chair confined and currently has a decubitus ulcer on a heel or elbow OR beneficiary exhibits signs of redness or discomfort at bony prominences or other areas of potential breakdown

One of the three listed criteria must be met

Urinary catheters

Catheter coverage criteria: Beneficiary has an acute condition requiring intermittent catheterization for measuring residual, medication instillation, or other medically necessary indication OR beneficiary has an acute condition requiring short‑term use of an indwelling catheter OR beneficiary has a chronic condition where incontinence is exacerbating pressure sores that will not heal OR beneficiary requires accurate measurement of intake and output on a short‑term basis OR beneficiary has urinary retention that cannot be relieved by medication

One of the listed conditions must be present

Supplies included: Covered supplies include insertion tray; irrigation tray with bulb or piston syringe; irrigation syringe; sterile solution for irrigation; female external collection device; indwelling catheters (two‑way and three‑way); male external catheter with or without adhesive; intermittent catheter, straight tip; bedside drainage bag; leg bag with or without strap; and sterile gloves

List of catheter supplies from Rule 2.2

Competency requirement: Beneficiary and/or caregiver must be capable of performing the catheterization procedure, have been instructed, and properly demonstrated ability to perform the procedure

Incontinence garments and supplies

Incontinence garments and supplies (age 3+)

Age and diagnosis: Beneficiary aged 3 years or older with a diagnosis of incontinence OR meets one of the following due to a documented medical condition: inability to utilize regular toilet facilities; inability to physically turn or reposition self; inability to transfer from bed to chair or wheelchair without assistance

Physician must order and document diagnosis

Quantity limits and prior authorization: Up to six (6) units of incontinence garments per day are covered; prior authorization is required for quantities in excess of the limit. Incontinence supplies limits: up to 400 personal sanitary wipes per month; up to 200 pairs of non‑sterile gloves per month; up to 2 units of non‑medicated skin protectant per month; prior authorization required for quantities in excess<=6 units/day; <=400 wipes/month; <=200 pairs gloves/month; <=2 skin protectant units/month

One unit equals one diaper or one pull‑on or one underpad; the six units may be any combination of diapers, pull‑ons, and/or underpads

Provider documentation and supply delivery:

Non-DME consumer electronics and personal devices (for example, a personal smartphone, tablet, or watch) are not covered as the DME receiver for Continuous Glucose Monitoring (CGM) systems. The policy permits coverage of a DME receiver when it is used alone or together with a non-DME device, but explicitly states that non-DME devices will not be covered as the DME receiver; furthermore, if a DME receiver is never used, the CGM supply allowance will not be covered.

Continuous Glucose Monitoring (CGM) supplies are allowed only as the specified bundled allowance that includes disposable sensors and the transmitter. Supplies billed separately will not be covered, so suppliers must bill the bundled sensor/transmitter allowance rather than submitting separate line items for individual CGM components.

Medical Necessity Criteria

General medical necessity

General rule

Medical necessity and standard care: Supplies are covered when medically necessary and considered standard care for treatment and are dispensed in quantities that meet beneficiary needs without excessive utilization

Lead‑in general medical necessity rule from Rule 2.2

Urinary catheter medical necessity

Catheter-specific necessity

Urinary catheter necessity: Acute need for intermittent catheterization for measuring residual or instilling medication OR acute need for short‑term indwelling catheter OR chronic condition where incontinence exacerbates pressure sores that will not heal OR need for accurate short‑term intake and output measurement OR urinary retention not relieved by medication

One criterion required for catheter coverage

Codes, Limits, and Quantity Rules

HCPCS codes referenced for item descriptionHCPCS

No codes listed

HCPCS codes requirement (CMN)HCPCS

No codes listed

inv-09: Incontinence garments per day — <= 6 units/day (age 3+)

LimitUp to 6 units per day for beneficiaries age 3 and above (one unit = one diaper, pull-on, or underpad)

Prior AuthorizationRequired for quantities in excess of 6 units per day

Unit compositionThe six units may be any combination of diapers, pull-ons, and/or underpads

inv-10: Personal sanitary wipes per month — <= 400 per month

Monthly limitUp to 400 personal sanitary wipes per month for beneficiaries age 3 and above when medically necessary

Medical necessityCovered when beneficiary is age 3+ and supplies are certified as medically necessary

Provider Requirements and Billing Rules

Prior Authorization

Prior authorization required for excess incontinence quantities

Prior authorization is required when requested quantities of incontinence garments or incontinence supplies exceed the specified daily or monthly limits (e.g., more than six incontinence garments per day for beneficiaries age 3+ or quantities above the monthly limits for wipes, gloves, or skin protectant).

Applies to both garments (diapers, pull-ons, underpads) and supplies (personal wipes, non-sterile gloves, non‑medicated skin protectant).
Providers must request prior authorization before dispensing quantities above the listed limits.

Step Therapy

Beneficiary/caregiver must demonstrate catheterization ability

The beneficiary and/or caregiver must be capable of performing catheterization, have been instructed in the procedure, and have properly demonstrated the ability to perform and report results for catheter supplies to be covered.

Requirement applies to intermittent catheterization and other catheter-related supplies listed in the policy.

Required Documentation and Records

Documentation Required

Keep CMN current and renew per recertification intervals

Maintain a current physician's order and CMN to initiate or continue provision of incontinence garments and supplies; recertify every six (6) months, or every twelve (12) months when the medical condition justifies chronic status.

Documentation Required

Retain delivery and confirmation records

Keep delivery documentation on file that includes beneficiary name, date of delivery (date received and expected service period), delivery address, detailed description and quantity delivered, and recipient signature; document emergency-era alternate confirmations when used.

Key Definitions

inv-20: Certificate of Medical Necessity (CMN)

DefinitionA physician-signed Certificate of Medical Necessity (CMN) including initial physician order, beneficiary diagnosis with codes, anticipated frequency and duration, requested quantity per month, detailed item description with type/size and HCPCS code, and ordering physician signature and date

Renewal intervalCMN must be renewed every 6 months; for chronic conditions recertification required every 12 months

Documentation requirementDME provider must maintain the current CMN in the beneficiary's record to initiate or continue provision of incontinence garments and supplies

Background and Scope

This rule enumerates categories of medical supplies and DME-related supplies that the Division covers when they are medically necessary and represent the standard of care for treatment of the beneficiary’s condition. Coverage frequently requires a documented diagnosis and an order from a physician; for certain items (for example, CGM components) the policy defines allowed configurations and billing requirements that must be met for coverage to apply.

Excluded Items and Billing

CGM supplies billed separately instead of as the bundled disposable sensors and transmitter are not covered. Non-DME devices (such as personal smartphones, tablets, or watches) are not covered as the DME receiver; a separate DME receiver must be used for the CGM supply allowance to apply.

Policy Summary

PayerMississippi Division of Medicaid

PolicyCovered Medical Supplies (Rule 2.2)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Last ReviewJan 1, 2025

Next Review DateN/A

Key ActionObtain and maintain a physician-signed Certificate of Medical Necessity (CMN) and renew every 6 months (12 months for chronic cases).

SourceLink

On This Page

Competency requirement for coverage

DME provider must maintain a current Certificate of Medical Necessity (CMN) and physician's order including diagnosis, anticipated frequency/duration, requested monthly quantity, detailed item description with HCPCS code, and physician signature; CMN must be renewed every six months (or every 12 months for chronic conditions). Provider must maintain proof of delivery documenting beneficiary name, date and address of delivery, detailed description and quantity delivered, and recipient signature (alternate confirmation allowed during emergencies).

CMN renewal every 6 months; 12 months for chronic cases

DME provider must have current physician's order and CMN to initiate or continue provision; deliver no more than a one‑month supply per delivery as required by policy

Competency requirement:

Beneficiary and/or caregiver must be capable of performing catheterization and must have been instructed and demonstrated ability to perform the procedure

Coverage requires demonstrated capability

Incontinence garment medical necessity

Incontinence garment medical necessity (age 3+)

Clinical criteria for incontinence supplies: Diagnosis of incontinence OR inability to utilize regular toilet facilities OR inability to physically turn or reposition self OR inability to transfer from bed to chair or wheelchair without assistance

One of the listed criteria must be met for supplies to be medically necessary

Quantity limits and prior authorization: Coverage up to six (6) units per day for beneficiaries aged three and above when medically necessary; prior authorization required for quantities in excess. Monthly limits for supplies: personal sanitary wipes up to 400; non‑sterile gloves up to 200 pairs; non‑medicated skin protectant up to 2 units; prior authorization required for excess quantities<=6 units/day; <=400 wipes/month; <=200 pairs gloves/month; <=2 skin protectant units/month

One unit equals one diaper, one pull‑on, or one underpad

Documentation and CMN: Physician must order all incontinence garments and supplies and the DME provider must maintain a current CMN including initial order, diagnosis and codes, anticipated frequency/duration, requested monthly quantity, item description with HCPCS code, and physician signature; CMN renewal every 6 months (12 months for chronic cases) and proof of delivery documentation requiredCMN renewal every 6 months; 12 months for chronic cases

Provider must retain proof of delivery and other documentation in beneficiary record

Prior AuthorizationRequired for quantities in excess of 400 per month

inv-11: Non-sterile gloves per month — <= 200 pairs/month

Monthly limitUp to 200 pairs of non-sterile gloves per month for beneficiaries age 3 and above when medically necessary

Included as incontinence supplyNon-sterile gloves are listed among covered disposable incontinence supplies

Prior AuthorizationRequired for quantities in excess of 200 pairs per month

inv-12: Non-medicated skin protectant per month — <= 2 units/month

Monthly limitUp to 2 units of non-medicated skin protectant per month for beneficiaries age 3 and above when medically necessary

Covered itemNon-medicated skin protectant is explicitly listed among covered incontinence supplies

Prior AuthorizationRequired for quantities in excess of 2 units per month

Coverage contingent on documented instruction and demonstrated ability.

Documentation Required

Maintain current physician-signed CMN with required details and renewals

The DME provider must maintain a current Certificate of Medical Necessity (CMN) signed and dated by the ordering physician that includes the initial physician order, beneficiary diagnosis with codes, anticipated frequency/duration, requested monthly quantity, detailed item description with type/size and HCPCS code, and the physician's signature; the CMN must be renewed every six months (or every 12 months for chronic conditions).

Signature stamps, date stamps, or signatures of anyone other than the ordering physician are not acceptable.
A current physician's order and CMN are required to initiate or continue provision of incontinence garments and supplies.

Documentation Required

Retain proof of delivery with beneficiary details and recipient signature

Keep proof of delivery documentation on file that shows beneficiary name, date the beneficiary received the item (and the dates of service the delivered quantity is expected to last), delivery address, detailed description of items delivered, quantity delivered, and the signature of the beneficiary, caregiver, or family member (a signature may be waived during a national or statewide emergency).

Document the expected span of service the delivered quantity will cover (dates of service).
During national or statewide emergencies, record the alternate confirmation method and that the emergency justified waiving a signature.

Denial Risk

Do not bill CGM sensors/transmitter separately — separate billing denies coverage

Continuous glucose monitoring (CGM) supply allowance covers disposable sensors and transmitter as a bundled allowance; supplies billed separately instead of as the allowed bundle will not be covered.

If a DME receiver is never used, the supply allowance will not be covered.
Non‑DME devices (e.g., personal smartphone, tablet, watch) are not covered as the DME receiver.

Prior Authorization

Prior authorization required when garments exceed 6 units/day (age 3+)

Prior authorization is required for incontinence garment quantities in excess of six units per day for beneficiaries aged three and older; one unit equals one diaper, one pull-on, or one underpad, and the six-unit daily limit may be any combination of those items.

Providers must obtain prior authorization before dispensing more than six units per day for age 3+ beneficiaries.
This per‑day limit applies only when garments are certified as medically necessary.