Participant Name:
SAR #:
SAR Submit Date:
NC Innovations Waiver and B3 DI (with U4 modifier)
Assistive Technology Equipment and Supplies—T2029
Met
Not
Met
N/A
Criteria to Approve Service
The request is for equipment /supplies that are necessary to increase, maintain, or improve
functional capabilities of participants.
The request includes purchases, leasing, shipping costs, or repair of equipment required to enable
beneficiaries to increase, maintain or improve their functional capacity to perform daily life tasks
that would not be possible otherwise.
Request includes three (3) separate, comparable quotes from approved vendors (one quote
minimum with explanation present) less than 90 days old on date request was submitted, unless
otherwise specified. One quote is acceptable for required for repairs or specialized equipment.
The quote submitted itemizes shipping costs that are to be included in the cost.
The request includes a written assessment or recommendation (LMN) by an appropriate
professional (i.e., PT, OT, ST, Physician) that identifies the participant’s needs and how the
equipment /supplies will meet those needs. The written assessment/ recommendation is less than
one calendar year old (from receipt date of the request) and explains how the item(s) requested
address a need that cannot be met by equipment or supplies on the State Medicaid Plan. The
request includes the estimated life of the equipment requested and length of time the beneficiary is
expected to benefit from the equipment.
Supplies that continue to be needed at the time of the beneficiary’s Annual Plan must be
recommended by an annual re-assessment by an appropriate professional. The assessment or
recommendation must be updated if the amount of the item the beneficiary needs changes.
The request includes a physician’s signature/prescription certifying medical necessity of the
requested equipment or supplies and is less than one calendar year old on the date the request was
submitted. A new physician’s signature is not required for repairs.
For supply requests, the recommendation must state the amount the participant needs.
The request is for a covered item listed in Policy 8P. Covered items include Aids for Daily Living,
Adaptive Tricycles for gross motor development, environmental control, positioning systems, alert
systems and repair of equipment. List the specific covered item that is listed in policy:
The requested items are of direct or remedial benefit to the beneficiary.
The service request includes long-range outcomes related to training needs associated with the
beneficiary’s or family’s utilization and procurement of the requested equipment or adaptations as
appropriate. This includes a plan for training the beneficiary, the natural support system and paid
caregivers on the use of requested equipment and supplies.
Adaptive Car Seat Requests: Request documents that the car seat is necessary for positioning a
child or adult who requires specialized seating while being transported due to chronic health issues.
Adaptive Car Seat Requests: Request is not for a car seat to be used for behavioral restraint.
Adaptive Car Seat Requests: Assessment includes
o Participant’s weight AND
o Weight limits of car seat currently used to transport AND
o Documentation that the participant has a seat to crown height that is longer than the back
height of the largest child car safety seat if the beneficiary weighs less than the upper
weight limit of the current car seat AND
o Reasons why participant cannot be safely transported in car seat belt or convertible/
booster seat for individuals weighing >30 pounds, AND
o Certification of medical necessity.
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Assistive Technology/Supplies/Equipment
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Alert System Requests: Request meets one the following:
o Participant lives alone or is alone for significant parts of the day OR
o Participant has no regular caregiver for extended periods of time and would otherwise
require extensive routine supervision OR
o Participant lives in a private home and the use of the equipment results in a fading or
reduction of paid services or prevents the need for additional paid services.
Nutritional Supplements: Participant is at least 18 years old and the requested supplement has
been prescribed by a physician deeming medical necessity for supplements to be taken by mouth
only.
Repair Only: Equipment to be repaired is owned by the recipient.
Repair Only: Equipment has been reasonably cared for and maintained.
Repair Only: Item was purchased through the waiver or is covered under the service definition.
Repair Only: Cost of repair does not exceed the cost of purchasing a replacement item.
The request equipment/supplies do not exceed $15,000 over duration of the waiver. (This limit does
not include nutritional supplements and monthly alert monitoring system charges.)
The request does not include a restrictive device as defined under North Carolina Client Rights Rules
The request does not include Service or Maintenance Contracts or extended warranties.
Request does not include equipment or supplies purchased for exclusive use at the school or home
school
The request does not include duplicate equipment because the recipient resides or visits in two
households. Duplicate equipment is not requested unless the ISP and assessments clearly document
the need for multiple items.
The request does not include computer desks or other furniture items.
The request is not for a Computer to be used to improve socialization or educational skills, to
provide recreation or diversion activities, or to be used by any other person other than the
beneficiary.
Request does not include a positioning chair or sitter for participants who use a wheelchair for
mobility.
Initial Review:
All Criteria Met:
YES—APPROVE (Nutritional Supplements only)
NO (send to Clinical Reviewer)
Note: All Assistive Tech requests (except Nutritional Supplements/B Codes) must be reviewed by Clinical Reviewer.
Reviewer Name, Credentials:
Date:
Comments:
Clinical Review:
Approved
Send to Peer Review
Reviewer Name, Credentials:
Date:
Comments:
1/1/2015
Assistive Technology/Supplies/Equipment
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