For Dates of Service Before January 1, 2018

Adaptive Equipment

PA is not required for the adaptive equipment in the following list:

• Adaptive eating utensil, weighted handle, any size, style, or shape.
• Adaptive eating utensil, non-weighted handle, any size, style, or shape.
• Rocker knife.
• Plate guard.
• Scoop dish.
• Universal cuff.
• Dycem, any size or shape.
• Reacher.
• Sock/stocking aid.
• Dressing stick.
• Long-handled shoe horn.
• Adaptive hygiene aids, such as a long-handled sponge.

PA is required for other adaptive equipment not listed above. Use HCPCS procedure code E1399 (Durable medical equipment, miscellaneous) when submitting PA requests for these items.

Providers are required to complete a PA/RF and a PA/DMEA. The PA request must adequately describe the DME item.

Modifiers "U1"-"U9" and "UA"-"UD" will be assigned on approved PA requests to distinguish between items when procedure code E1399 is used more than once. If submitting the PA request via the ForwardHealth Portal, providers should specify the requested equipment with the requested charges in the additional space on the PA/DMEA.

The PA request for adaptive equipment should include sufficient information to confirm the medical necessity of the requested item(s), including the following:

• A complete description of the item being requested with brand/model number.
• The member's diagnosis(es) and the date of onset.
• The specific medical condition that necessitates the use of the requested equipment.
• A description of the member's ability to complete ADL independently, with a caregiver, or with adaptive equipment.
• Caregiver information (e.g., availability, duties, and whether the caregiver is a spouse, other family member, home health aide).
• Specific results of trial use of the adaptive equipment or report of therapy service, if available.