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The following updates to coverage, criteria, and billing are effective April 1, 2025.

1.     The following criteria updates have been made for diapers and pull-ups:

a.     Pull-ups will be approved for EPSDT recipients who meet coverage criteria.

b.     To align with developmental guidelines, coverage criteria for diapers and pull-ups have been updated to require that the recipient is at least 3 years old if non-ambulatory, and at least 5 years old if minimally or fully ambulatory.

c.     Documentation must include evidence of failed toileting training/therapy and must describe recipient specific disability limitations affecting toileting.

d.     Recipients will not receive approval for both diapers and pull-ups in the same benefit period. If a recipient needs to obtain pull-ups and has an approved prior authorization (PA) for diapers, the PA for the diapers must be end-dated prior to the effective date for pull-ups.

e.     Recipients 3-4 years old with a PA approved prior to April 1, 2025, for diapers or pull-ups will continue to receive these items unless there is a change in disability/medical status.

2.     The following updates have been made for enteral supplies:

a.     Farrell valve bags will be billed using B9998 for PAs beginning on or after April 1, 2025. The limit will be 1 case (qty 30 bags) per 30 days, up to 13 cases per year. Reimbursement will remain provider final invoice cost plus 20%.

b.     Mic-Key extension sets will continue to be billed on B9998 with an increased limit of 4 per month, and the reimbursement amount will remain $20 per unit.

c.     Both items will be billed electronically if within the limit. Over the limit requests may require paper billing.

3.     The following updates have been made for non-invasive (E0466) and invasive ventilators (E0465):

a.     Both E0466 and E0465 will be covered for adults who meet medical necessity criteria.

b.     All claims for E0466 and E0465 with a date of service on or after April 1, 2025, will be billed electronically.

4.     The following updates have been made for wheelchair accessories:

a.     Per CMS guidelines E1028 is being split to allow for more detailed and accurate billing. As part of this directive, the description for E1028 is changing.

b.     E1028 “Wheelchair accessory, manual swing away, retractable or removable mounting hardware, other.”

c.     E1032 “Wheelchair accessory, manual swing away, retractable or removable mounting hardware used with joystick or other drive control interface.”

d.     E1033 “Wheelchair accessory, manual swing away, retractable or removable mounting hardware for headrest, cushioned, any type.”

e.     E1034 “Wheelchair accessory, manual swing away, retractable or removable mounting hardware for lateral trunk or hip support.”

f.      E1032, E1033, and E1034 should only be requested on PAs with an effective date of April 1, 2025, or later and should only be billed on dates of service on or after April 1, 2025.

Policy questions concerning this provider notice should be directed to the DME Program at (334) 242-5050.

The Current Procedural Terminology (CPT) and Current Dental Terminology (CDT) codes descriptors, and other data are copyright © 2025 American Medical Association and © 2025 American Dental Association (or such other date publication of CPT and CDT). All rights reserved. Applicable FARS/DFARS apply.