Wv Medicaid Dme Prior Authorization Request Form (Dme) Page 2
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2
3LIST DME CPT/HCPC:
MAKE A COPY OF THIS PAGE FOR MULTIPLE CPT/HCPC CODES AND SUBMIT A PAGE PER
CPT/HCPC-Quantity Ordered
Frequency of Use
ICD DX Code(s)
Symptoms:
Date of Anticipated Equipment Replacement
$
DME Vendor Cost Quote
ATTACH Cost Invoice/Calculation
Clinical Indications for Items Requested—Mark all Applicable
Medical Equipment
General Medical Equipment
Other Medical Equipment:
____________________________________________________
Enteral Nutrition
, If Yes-Enteral Feedings Product___________________________________ Enteral Feedings Frequency________________________
PLEASE CIRCLE ALL APPLICABLE CRITERIA BELOW FOR ENTERAL NUTRITION:
a)
Permanent Impairment > 90 days from onset
b)
Caloric Intake > 50% Daily
c)
Impaired digestion, malabsorption or nutritional risk as indicated in anthropometric measures
d)
Weight loss for adults showing: Involuntary or acute weight loss greater than or equal to 10% of usual body weight during a 3-6 month period or BMI below 18.5
kg/m2.
e)
Weight loss for neonates, infants and children showing: Very low birth weight(LBW)even in the absence of gastrointestinal, pulmonary or cardiac disorders. Lack of
weight gain or weight gain less than 2 standard deviations below the age appropriate mean in a 1 month period for children under 6 months or in a 2 month period
for children 6-12 months. No weight gain or abnormally slow rate of gain for 3 months for children older than 1 year or documented weight loss does not reverse
promptly with instruction in appropriate diet for age. Weight for height less than the 10th percentile.
f)
Abnormal laboratory test pertinent to the diagnosis
g)
Anatomic structure of the gastrointestinal tract that impairs digestion and absorption
h)
Diagnosis of inborn errors or metabolism that require food products modified low in protein
i)
Failure to Thrive(FTT) diagnosis that increases caloric need while impairing caloric intake and/or retention
j)
Increased metabolic and/or caloric needs due to excessive burns, infection, trauma, prolonged fever, hyperthyroidism or illnesses that impair caloric intake and/or
retention
k)
Neurological disorders that impair chewing or swallowing
l)
Prolonged nutrient losses due to malabsorption syndromes or short bowel syndrome, diabetes, celiac disease, chronic pancreatitis, renal dialysis, draining abscess or
wounds
m)
Treatments with anti-nutrient or catabolic properties
Feeding Tube
IV Infusion Therapy
Mobility and Bathroom Safety Aids
Bathroom Safety Aids
LIST Other Mobility Aids: ________________________________________
Wheelchair: Manual
Power (Be sure to Complete Page 3)
Medical Supplies
Ostomy Supplies
Incontinence Supplies, CIRCLE reason below:
a)
Patient has a congenital urinary tract abnormality causing incontinence c) Patient has a developmental delay with urogenital sequalae
b)
Patient has a neuromuscular defect causing incontinence
d) Other clinical evidence to support incontinence or inability to toilet train
Respiratory Equipment
BiPAP
CPAP
Nebulizer
Respiratory Equip-Ventilator
Oxygen(02)
Oxygen Liters or % of O2 Administered: _______________________________________
Oxygen Saturation:________________________________________
•
Respiratory Equip-Breathing Treatment
Breathing Treatment-Medication Administered_________________________________________ Breathing Treatment-Frequency________________________
•
Infant Apnea Monitors
a)
Birth Weight____________________________
Gestational Age(in weeks)_____________________________
b)
Sibling of SIDS
Yes
No
c)
Infant with Narcotic Addict Mother
Yes
No
d)
Infant with High-Risk Cardiac Disease
Yes
No
e)
Infant with Tracheostomy
Yes
No
f)
Prematurity
Yes
No
g)
Parent/Guardian Certification (Attached
Yes
No )
h)
Apnea Delay Rate(in seconds)__________________________
i)
Apparent Life Threatening Event(ALTE)
Yes
No If Yes, complete below and attach all relevant ALTE documentation. Date of ALTE______________
Number of ALTE Episodes__________ ALTE Hospital Name___________________________________________________________________________________
ALTE Hospital Admission Date ______________________ Discharge Date __________________Follow-up appointment date: _____________________________
Other: _____________________________________________________________________________________________________________
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