The following items shall not be covered:

1. (a) Items that do not meet the coverage criteria set forth in He-W 571.04;
2. (b) Specialty formulas when not needed for life-sustaining purposes, or as the sole source of nutrition, except as allowed under He-W 546;

3. (c) Common, over-the-counter, household and medicine-chest items that can be purchased without a prescription, including, but not limited to:

   1. (1) Corn plasters and foot pads;
   2. (2) Nursery supplies;
   3. (3) Hand cleaners or sanitizers, such as Hygenall or Purell;
   4. (4) Personal hygiene items including body lotions, toothbrushes, electric shavers, razors, and other hair removal devices and services;
   5. (5) Thermometers;
   6. (6) Odor barrier products;
   7. (7) Toileting wipes, except as allowed by He-W 571.04(c)(18) above;
   8. (8) First aid kits and supplies, including adhesive bandages and scissors;
   9. (9) Mechanical heated water circulating pads and pumps, including hydrocollator heating units;
   10. (10) Non-legend medications specified in accordance with He-W 570.05(d); and

   11. (11) Nutritional supplements or formula as follows:

       1. a. Dietary or food supplements;
       2. b. Lactose-free foods or products that aid in lactose digestion;
       3. c. Gluten-free products;
       4. d. Low carbohydrate diets;
       5. e. Weight-loss foods, formulas, and related products intended to aid in weight loss;
       6. f. Normal grocery items, including over-the counter infant formulas;
       7. g. Baby food and banked breast milk;
       8. h. Grocery items that can be prepared in a blender and used with an enteral feeding system;
       9. i. High protein powders and mixes;

       10. j. Medical food products that:

           1. 1. Are prescribed without a diagnosis requiring such foods;
           2. 2. Used for convenience purposes;
           3. 3. Have no proven therapeutic benefit without an underlying disease, condition, or disorder;
           4. 4. Used as a substitute for acceptable standard dietary interventions; or
           5. 5. Are used exclusively for nutritional supplementation; and
       11. k. Enteral nutrition when the recipient has food allergies or dental problems, but has the ability to meet his or her nutritional requirements through an alternative store-bought food source;

4. (d) Environmental modifications and controls, including:

   1. (1) Wheelchair ramps;
   2. (2) Tub rails;
   3. (3) Space heaters and heat lamps;
   4. (4) Air conditioners and fans;
   5. (5) Air purifiers, including HEPA and vacuum filters;
   6. (6) Vaporizers, humidifiers, and dehumidifiers;
   7. (7) Aromatherapy;
   8. (8) Stairway lifts and elevators;
   9. (9) Lifting devices including electric patient lifts and hydraulics and ceiling tract lifting devices;
   10. (10) Power generators; and
   11. (11) Adaptive or computer switch toys;

5. (e) Items typically not used by the general public for a medical purpose, including:

   1. (1) Furniture for non-mobility purposes including, but not limited to:

      1. a. Corner seats;
      2. b. Positioning chairs;
      3. c. High chairs or other feeding type chairs;
      4. d. All beds, except hospital beds as allowed by He-W 571.04(c)(20)c., and the pediatric specialty beds as allowed in He-W 571.04(c)(20) above;
      5. e. Toddler beds, bassinets, portable cribs, or playpens; and
      6. f. Massage and therapy tables and related equipment;
   2. (2) Lumbar support cushions;
   3. (3) Bedding, including electric or weighted blankets;
   4. (4) Clothing items, including sportswear such as neoprene shorts;
   5. (5) Hot Tubs, whirlpool equipment, aqua massagers, and sauna baths;
   6. (6) Recreational, therapeutic, or exercise equipment including, but not limited to, bicycles, treadmills, weights, tables, mats, and swings; and
   7. (7) Video, computer games, or computer applications intended for the purpose of exercise, recreation, education, or instruction;
6. (f) Items that contribute to or enhance fertility or procreation;

7. (g) Items typically used by the general public for preventing injury or ensuring safety, including:

   1. (1) Car seats, except as allowed by He-W 571.04(d)(1);
   2. (2) Helmets, including protective helmets used for sports and recreation, except as allowed by He-W 571.04(d)(2); and
   3. (3) Pneumatic vests and lumbar supports;

8. (h) Disposable incontinence supplies for:

   1. (1) Recipients younger than 3 years of age, except as allowed by He-W 546; and
   2. (2) Recipients 21 years of age or older who do not meet the criteria set forth in He-W 571.04(c)(18);
9. (i) Bed wetting alarms;
10. (j) Sleep positioning wraps;
11. (k) Computer controlled and programmable lateral rotation therapy bed systems;
12. (l) Chewelry, and similar non-toxic jewelry, intended to be chewed;
13. (m) Magnets, crystals, gemstones, and similar non-evidenced based, experimental, or investigational healing items;
14. (n) Glucowatches;
15. (o) Auto-feeders;
16. (p) Automated medication reminder systems;
17. (q) Cast bags, such as Aquashield;
18. (r) Electric resuscitators and portable defibrillators;
19. (s) Bi-directional static progressive stretch devices, including, but not limited to, Joint Active Systems (JAS) splints;
20. (t) Service or therapy animals and related expenses;
21. (u) Apnea monitors, except when the criteria in He-W 571.04(c)(2) have been met;
22. (v) Prosthetic fingers, thumbs, and toes when not part of a covered prosthesis;
23. (w) Commercially available strollers;
24. (x) Wheelchairs requested within 24 months of the purchase of a customized stroller;

25. (y) The following accessories and options for wheelchairs, customized strollers, or other mobility devices:

    1. (1) Wheelchair remote controls and attendant control switches;
    2. (2) Power assist devices or equipment to modify a manual wheelchair into a power wheelchair;
    3. (3) Air suspension systems;
    4. (4) Power standers and seat lift mechanisms;
    5. (5) Grade aids and anti-roll devices for manual wheelchairs;
    6. (6) Wheelchairs with stair climbing options;
    7. (7) Titanium framed and sport-type wheelchairs;
    8. (8) Custom wheels for off-road use or for sport and recreational purposes;
    9. (9) Any wheelchair accessory or option for purposes of allowing the recipient to perform leisure, social, or recreational activities;
    10. (10) Lights, horns, mirror, baskets, pouches, backpacks, and similar accessories; and
    11. (11) Back-up or spare wheelchairs for recipients who already have a wheelchair, power scooter, or customized stroller;
26. (z) Any back-up or spare equipment, with the exception of ventilators;

27. (aa) Replacement, repair, or modifications of an item when the need for which is the result of:

    1. (1) Recipient abuse, misuse, or neglect;
    2. (2) Failure to protect the item from the elements;
    3. (3) Using the item inappropriately or contrary to its designed and intended use;
    4. (4) Making improper repairs to the item, which would void any manufacturer’s warranty;
    5. (5) Loss of the item when basic safeguarding measures could have been instituted;
    6. (6) Failure to maintain the item through proper routine maintenance by an authorized dealer; or
    7. (7) Taking any action that would otherwise void the manufacturer’s written warranty or is contrary to the manufacturer’s recommendations for care, use, and maintenance;
28. (ab) Repairs, modifications, or adjustments to any rented item, including wheelchairs;

29. (ac) Repairs to recipient owned items, when the recipient does not meet the criteria for coverage of the item, or when such repairs, modifications, or adjustments are:

    1. (1) Within the dispensing provider’s or manufacturer’s warranty; or
    2. (2) Within one year of the purchase of the item or accessory, unless written documentation from the provider demonstrates a significant change in the recipient’s medical condition that meets the coverage criteria for the item and the repair or modification is warranted;
30. (ad) Upgrades to or replacement of any functioning item that still meets the recipient’s needs, but is being requested solely as a result of changing technology;
31. (ae) Items which are more costly than other available items which could be expected to provide the same, similar, or duplicate outcome;
32. (af) Any items that are primarily intended for use at a school, are part of a child’s care plan at school, and could be obtained through the “Medicaid to Schools” program in accordance with He-M 1301, and the child and the child’s school participate in the “Medicaid to Schools” program; and
33. (ag) Any items that are experimental, investigational, or non-FDA approved.

Source. (See Revision Note at chapter heading He-W 500); ss by #6158, eff 12-29-95, EXPIRED: 12-29-03 New. #8961, eff 8-20-07; amd by #8983, INTERIM, eff 9-21-07, EXPIRES: 3-19-08; amd by #9103, eff 3-12-08; amd by #9637, eff 1-16-10; amd by #9836, eff 12-18-10; ss by #11046, eff 2-27-16 (from He-W 571.05)