Cal. Code Regs. tit. 22 § 51321

Current through Register 2024 Notice Reg. No. 45, November 8, 2024

Section 51321 - Durable Medical Equipment

(a) Durable medical equipment, as defined in Section 51160, is covered in accordance with the standards set forth in section 51303(a) and when provided on the written prescription of licensed practitioners within the scope of their practice as established in California law. Alterations or improvements of real property are not covered except to the extent authorized for the provision of home dialysis services. In addition to the prescribing practitioner's signature, all of the following specific information, at a minimum, shall be clearly provided on, or with the prescription form, or as an attachment to the Treatment Authorization Request:

(1) Full name and telephone number of the prescribing practitioner.

(2) Date of prescription.

(3) Specific item(s) being prescribed.

(4) Patient's medical condition/diagnosis necessitating each item. This documentation shall include:

(A) The patient's medical status and functional limitation(s) and

(B) A description of the manner in which the specific item being requested is expected to improve the medical status or functional ability of the patient, stabilize the patient's condition, or prevent additional deterioration of the medical status or functional ability of the patient.

(5) Estimated length of time the item is determined to be medically necessary.

(b) Prior authorization is required:

(1) For the purchase of durable medical equipment listed in Section 51521 when the cumulative cost within the calendar month of purchasing items within a group exceeds $100.00.

(2) For the repair or maintenance of durable medical equipment when the cumulative cost within the calendar month exceeds $250.00 for the repair and maintenance of items within a group, and when the cumulative cost of renting items within a group exceeds $50.00 within a fifteen month period. The cost of repairs shall not exceed the replacement value of the item being repaired.

(3) For the provision of oxygen, Procedure Code E0441, when more than the equivalent of two H tanks (which equals 10 "E" tanks or 500 cu. ft.) are provided during one calendar month.

(4) For the purchase, rental, repair or maintenance of any unlisted devices or equipment, regardless of the dollar amount.

(c) All authorization requests shall, at a minimum, include all of the following:

(1) Identification of patient; name and patient Medi-Cal identification or Social Security number.

(2) Date of request.

(3) Medical justification relevant to the item being requested.

(4) Location where patient resides.

(5) Description of item, including:

(A) Manufacturer's name and/or model type/serial number, as applicable.

(B) Procedure Code.

(C) Estimated length of need, whether rental or purchase of the item is requested, and associated charges. Except for life support equipment, such as ventilators, and other equipment that requires ongoing service or maintenance, when previously paid rental charges equal the maximum allowable purchase price of the rented item, as specified in Section 51521(i), the item is considered to have been purchased and no further reimbursement to the provider shall be made unless repair or maintenance of the item is separately authorized. When the Department determines it is medically necessary to purchase an unlisted item of durable medical equipment that had been rented for a Medi-Cal patient, the Department and the provider shall determine the purchase price and the amount of the rental charges that may be applied to the purchase price.

(6) Rendering provider identification, including name, address, telephone number, contact name, contact telephone number, and Medi-Cal provider I.D. number.

(d) In addition to the documentation requirements specified in (c) above, authorization requests for unlisted durable medical equipment/devices also require copies of catalog pages and medical justification to substantiate why a listed item is insufficient to meet the patient's medical needs.

(e) The following items are not covered by the program:

(1) Modification of automobiles/or other highway motor vehicles

(2) Books or other items of a primarily educational nature

(3) Air conditioners, air filters, or heaters

(4) Food blenders

(5) Reading lamps, or other lighting devices

(6) Bicycles, tricycles, or exercise equipment, except as otherwise specified in this Chapter

(7) Television sets

(8) Orthopedic mattresses, recliners, rockers, seat lift chairs, or other furniture items

(9) Waterbeds

(10) Household items

(11) Other items not generally used primarily for health care and which are regularly and primarily used by persons who do not have a specific medical need for them.

(f) Authorization shall not be granted for medical equipment when a household or furniture item will adequately serve the patient's medical needs.

(g) Authorization for durable medical equipment shall be limited to the lowest cost item that meets the patient's medical needs.

(h) Authorization for durable medical equipment for skilled nursing facility/Level B or intermediate care facility/Level A inpatients may be approved as follows:

(1) The equipment is necessary for the continuous care of the patient to meet the unusual medical needs of that patient. A patient may be considered to have unusual medical needs when a disease or medical condition is exacerbated by physical characteristics such as height, weight, and body build. Physical characteristics, in and of themselves, shall not constitute an unusual medical condition.

(2) Canes, crutches, wheelchairs, wheelchair cushions, and walkers may be authorized only when the item must be custom made or modified to meet the unusual medical needs of the patient and the need is expected to be permanent. A custom wheelchair, either manual or power, is one which has been uniquely constructed or assembled to address a particular patient's individual medical needs for positioning, support and mobility.

(3) Suction and positive pressure apparatus may be authorized only when the item will be continuously used by the patient or must be immediately available to the patient for one month or more.

(i) Beneficiaries shall be responsible for appropriate use and care of durable medical equipment purchased for their use under the Medi-Cal program.

(j) Rendering providers of durable medical equipment shall ensure that all devices and equipment are appropriate to meet the beneficiary's medical needs. If a piece of equipment or a device, when in actual use, fails to meet the beneficiary's needs, and the beneficiary's medical condition has not significantly changed since the device/equipment was dispensed, the rendering provider shall adjust or modify the equipment, as necessary, to meet the beneficiary's needs. Any equipment or device that cannot be adjusted or modified, shall be replaced by the rendering provider at no cost to the Medi-Cal program.

(k) In addition to the requirements specified in subsections (a) through (j) above, authorization of the following shall be made in accordance with the criteria contained in the applicable chapter of the Manual of Criteria for Medi-Cal Authorization:

(1) Antidecubitus Care (ADC) Support Surfaces--Chapter 13.1.

(2) Osteogenesis Stimulator Devices to Accelerate the Healing of Selected Bone Fractures--Chapter 13.2.

Cal. Code Regs. Tit. 22, § 51321

1. Amendment of subsections (b) and (c) filed 11-4-76; effective thirtieth day thereafter (Register 76, No. 45). For prior history, see Register 72, No. 31.
2. Amendment of subsection (b) filed 5-25-77; effective thirtieth day thereafter (Register 77, No. 22).
3. Amendment of subsection (h) filed 8-8-78; effective thirtieth day thereafter (Register 78, No. 32).
4. Amendment of subsection (a) filed 9-1-82 as an emergency; effective upon filing (Register 82, No. 37). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 12-30-82.
5. Certificate of Compliance transmitted to OAL 12-28-82 and filed 1-21-83 (Register 83, No. 4).
6. Amendment of subsections (b) and (c) filed 11-7-86; effective thirtieth day thereafter (Register 86, No. 45).
7. Change without regulatory effect of NOTE (Register 86, No. 49).
8. Amendment filed 5-25-89; operative 6-24-89 (Register 89, No. 21).
9. Amendment filed 12-10-90 as an emergency; operative 12-10-90 (Register 91, No. 6). A Certificate of Compliance must be transmitted to OAL by 4-9-91 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 12-10-90 order transmitted to OAL 4-8-91 and filed 5-8-91 (Register 91, No. 24).
11. Amendment of subsection (b) filed 9-25-92 as an emergency; operative 10-1-92 (Register 92, No. 40). A Certificate of Compliance must be transmitted to OAL 1-25-93 or emergency language will be repealed by operation of law on the following day.
12. Certificate of Compliance as to 9-25-92 order transmitted to OAL 1-22-93 and filed 3-9-93 (Register 93, No. 11).
13. Amendment of subsection (b) and NOTE filed 5-18-94; operative 6-17-94 (Register 94, No. 20).
14. Amendment of subsection (b) filed 8-2-95 as an emergency; operative 8-2-95 (Register 95, No. 31). A Certificate of Compliance must be transmitted to OAL by 11-30-95 or emergency language will be repealed by operation of law on the following day.
15. Certificate of Compliance as to 8-2-95 order transmitted to OAL 11-22-95 and filed 1-3-96 (Register 96, No. 1).
16. Amendment of subsection (g) and NOTE filed 4-1-96 as an emergency; operative 4-1-96 (Register 96, No. 14). A Certificate of Compliance must be transmitted to OAL by 9-30-96 pursuant to Welfare and Institutions Code section 14132.22 or emergency language will be repealed by operation of law on the following day.
17. Editorial correction of HISTORY 16 (Register 96, No. 35).
18. Amendment of subsection (g) and NOTE refiled 8-28-96 as an emergency; operative 9-30-96 (Register 96, No. 35). A Certificate of Compliance must be transmitted to OAL by 1-28-97 or emergency language will be repealed by operation of law on the following day.
19. Certificate of Compliance as to 8-28-96 order transmitted to OAL 1-23-97 and filed 3-10-97 (Register 97, No. 11).
20. Amendment filed 6-5-2000 as an emergency; operative 6-5-2000 (Register 2000, No. 23). A Certificate of Compliance must be transmitted to OAL by 10-3-2000 or emergency language will be repealed by operation of law on the following day.
21. Amendment refiled 8-21-2000 as an emergency; operative 10-3-2000 (Register 2000, No. 34). A Certificate of Compliance must be transmitted to OAL by 1-31-2001 or emergency language will be repealed by operation of law on the following day.
22. Amendment of subsection (k) and new subsections (k)(1)-(2) filed 9-22-2000 as an emergency; operative 9-22-2000 (Register 2000, No. 38). A Certificate of Compliance must be transmitted to OAL by 1-22-2001 or emergency language will be repealed by operation of law on the following day.
23. Amendment of subsection (k) and new subsections (k)(1)-(2) refiled 1-23-2001 as an emergency; operative 1-23-2001 (Register 2001, No. 4). A Certificate of Compliance must be transmitted to OAL by 5-23-2001 or emergency language will be repealed by operation of law on the following day.
24. Certificate of Compliance as to 8-21-2000 order, including further amendment of subsections (a), (a)(4)(B), (b)(2), (c)(5)(C), (e)(1) and (h)(2), transmitted to OAL 1-3-2001 and filed 2-5-2001 (Register 2001, No. 6).
25. Certificate of Compliance as to 1-23-2001 order, including amendment of NOTE, transmitted to OAL 2-7-2001 and filed 3-16-2001 (Register 2001, No. 11).
26. Change without regulatory effect repealing and adopting new subsection (e)(11), repealing subsection (e)(12) and amending NOTE filed 5-13-2003 pursuant to section 100, title 1, California Code of Regulations (Register 2003, No. 20).
27. Change without regulatory effect amending section and NOTE filed 6-12-2006 pursuant to section 100, title 1, California Code of Regulations (Register 2006, No. 24).

Note: Authority cited: Sections 14105, 14124.5 and 14126.23, Welfare and Institutions Code; Section 100275, Health and Safety Code; Section 57(c), Chapter 328, Statutes of 1982; and Section 3, Chapter 1381, Statutes of 1990. Reference: Sections 14053, 14132, 14133, 14133.1(c) and 14133.3, Welfare and Institutions Code; Section 447.15, Title 42, Code of Federal Regulations; and Vera Blue, et al., v. Bonta' (2002) 99 Cal. App. 4th 980.

1. Amendment of subsections (b) and (c) filed 11-4-76; effective thirtieth day thereafter (Register 76, No. 45). For prior history, see Register 72, No. 31.
2. Amendment of subsection (b) filed 5-25-77; effective thirtieth day thereafter (Register 77, No. 22).
3. Amendment of subsection (h) filed 8-8-78; effective thirtieth day thereafter (Register 78, No. 32).
4. Amendment of subsection (a) filed 9-1-82 as an emergency; effective upon filing (Register 82, No. 37). A Certificate of Compliance must be transmitted to OAL within 120 days or emergency language will be repealed on 12-30-82.
5. Certificate of Compliance transmitted to OAL 12-28-82 and filed 1-21-83 (Register 83, No. 4).
6. Amendment of subsections (b) and (c) filed 11-7-86; effective thirtieth day thereafter (Register 86, No. 45).
7. Change without regulatory effect of NOTE(Register 86, No. 49).
8. Amendment filed 5-25-89; operative 6-24-89 (Register 89, No. 21).
9. Amendment filed 12-10-90 as an emergency; operative 12-10-90 (Register 91, No. 6). A Certificate of Compliance must be transmitted to OAL by 4-9-91 or emergency language will be repealed by operation of law on the following day.
10. Certificate of Compliance as to 12-10-90 order transmitted to OAL 4-8-91 and filed 5-8-91 (Register 91, No. 24).
11. Amendment of subsection (b) filed 9-25-92 as an emergency; operative 10-1-92 (Register 92, No. 40). A Certificate of Compliance must be transmitted to OAL 1-25-93 or emergency language will be repealed by operation of law on the following day.
12. Certificate of Compliance as to 9-25-92 order transmitted to OAL 1-22-93 and filed 3-9-93 (Register 93, No. 11).
13. Amendment of subsection (b) and Note filed 5-18-94; operative 6-17-94 (Register 94, No. 20).
14. Amendment of subsection (b) filed 8-2-95 as an emergency; operative 8-2-95 (Register 95, No. 31). A Certificate of Compliance must be transmitted to OAL by 11-30-95 or emergency language will be repealed by operation of law on the following day.
15. Certificate of Compliance as to 8-2-95 order transmitted to OAL 11-22-95 and filed 1-3-96 (Register 96, No. 1).
16. Amendment of subsection (g) and Note filed 4-1-96 as an emergency; operative 4-1-96 (Register 96, No. 14). A Certificate of Compliance must be transmitted to OAL by 9-30-96 pursuant to Welfare and Institutions Code section 14132.22 or emergency language will be repealed by operation of law on the following day.
17. Editorial correction of History 16 (Register 96, No. 35).
18. Amendment of subsection (g) and Note refiled 8-28-96 as an emergency; operative 9-30-96 (Register 96, No. 35). A Certificate of Compliance must be transmitted to OAL by 1-28-97 or emergency language will be repealed by operation of law on the following day.
19. Certificate of Compliance as to 8-28-96 order transmitted to OAL 1-23-97 and filed 3-10-97 (Register 97, No. 11).
20. Amendment filed 6-5-2000 as an emergency; operative 6-5-2000 (Register 2000, No. 23). A Certificate of Compliance must be transmitted to OAL by 10-3-2000 or emergency language will be repealed by operation of law on the following day.
21. Amendment refiled 8-21-2000 as an emergency; operative 10-3-2000 (Register 2000, No. 34). A Certificate of Compliance must be transmitted to OAL by 1-31-2001 or emergency language will be repealed by operation of law on the following day.
22. Amendment of subsection (k) and new subsections (k)(1)-(2) filed 9-22-2000 as an emergency; operative 9-22-2000 (Register 2000, No. 38). A Certificate of Compliance must be transmitted to OAL by 1-22-2001 or emergency language will be repealed by operation of law on the following day.
23. Amendment of subsection (k) and new subsections (k)(1)-(2) refiled 1-23-2001 as an emergency; operative 1-23-2001 (Register 2001, No. 4). A Certificate of Compliance must be transmitted to OAL by 5-23-2001 or emergency language will be repealed by operation of law on the following day.
24. Certificate of Compliance as to 8-21-2000 order, including further amendment of subsections (a), (a)(4)(B), (b)(2), (c)(5)(C), (e)(1) and (h)(2), transmitted to OAL 1-3-2001 and filed 2-5-2001 (Register 2001, No. 6).
25. Certificate of Compliance as to 1-23-2001 order, including amendment of Note, transmitted to OAL 2-7-2001 and filed 3-16-2001 (Register 2001, No. 11).
26. Change without regulatory effect repealing and adopting new subsection (e)(11), repealing subsection (e)(12) and amending Note filed 5-13-2003 pursuant to section 100, title 1, California Code of Regulations (Register 2003, No. 20).
27. Change without regulatory effect amending section and Note filed 6-12-2006 pursuant to section 100, title 1, California Code of Regulations (Register 2006, No. 24).