CSHCN 2009 >18.2 Benefits, Limitations, and Authorization Requirements

The CSHCN Services Program provides benefits for expendable medical supplies for eligible clients. An expendable medical supply is defined as an item necessary to carry out a medical procedure or to maintain the client's health at home.

Expendable is defined as being intended for single or short-term use before being discarded. Most supplies are not reusable and will be discarded after use. Some supplies, including but not limited to straight catheters, may be cleaned and reused. Supplies are a benefit only for those clients residing at home.

Expendable medical supplies are limited to a quantity used by the typical client.

Prior authorization is required with documentation of medical necessity supports additional quantities greater than maximum limitations listed in the tables below for a client with exceptional needs. Some expendable medical supplies related to feeding, incontinence supplies, and respiratory supplies are limited in the amounts allowed per month. The following tables provide listings of these supplies and limitation amounts.


Procedure Code	Maximum Limitation	Procedure Code	Maximum Limitation	Procedure Code	Maximum Limitation
A4310	2 per month	A4311	2 per month	A4312	2 per month
A4313	2 per month	A4314	2 per month	A4315	2 per month
A4316	2 per month	A4320	2 per month	A4322	4 per month
A4326	31 per month	A4327	4 per month	A4328	4 per month
A4330	As needed	A4335	2 per month	A4338	2 per month
A4340	2 per month	A4344	2 per month	A4346	2 per month
A4349	31 per month	A4351	120 per month	A4352	120 per month
A4353	120 per month	A4354	2 per month	A4355	2 per month
A4356	2 per month	A4357	2 per month	A4358	2 per month
A4361	As needed	A4362	As needed	A4363	As needed
A4364	As needed	A4365	1 per month	A4367	As needed
A4368	As needed	A4369	As needed	A4371	As needed
A4372	As needed	A4373	As needed	A4375	As needed
A4376	As needed	A4377	As needed	A4378	As needed
A4379	As needed	A4380	As needed	A4381	As needed
A4382	As needed	A4383	As needed	A4384	As needed
A4385	As needed	A4387	As needed	A4388	As needed
A4389	As needed	A4390	As needed	A4391	As needed
A4392	As needed	A4393	As needed	A4394	As needed
A4395	As needed	A4396	As needed	A4397	As needed
A4398	As needed	A4399	As needed	A4400	As needed
A4402	4 per month	A4404	As needed	A4405	As needed
A4406	As needed	A4407	As needed	A4408	As needed
A4409	As needed	A4410	As needed	A4411	As needed
A4412	As needed	A4413	As needed	A4414	As needed
A4415	As needed	A4421	As needed	A4422	As needed
A4452	As needed	A4455	4 per month	A4554	150 per month
A4927	1 per month	A5051	As needed	A5052	As needed
A5053	As needed	A5054	As needed	A5055	As needed
A5061	As needed	A5062	As needed	A5063	As needed
A5071	As needed	A5072	As needed	A5073	As needed
A5081	As needed	A5082	As needed	A5083	As needed
A5093	As needed	A5102	2 per month	A5105	4 per year
A5112	2 per month	A5113	2 per month	A5114	2 per month
A5120	1 per month	A5121	As needed	A5122	As needed
A5126	As needed	A5131	1 per month	A5200	2 per month
T4521	Limited per policy*	T4522	Limited per policy*	T4523	Limited per policy*
T4524	Limited per policy*	T4525	Limited per policy*	T4526	Limited per policy*
T4527	Limited per policy*	T4528	Limited per policy*	T4529	Limited per policy*
T4530	Limited per policy*	T4531	Limited per policy*	T4532	Limited per policy*
T4533	Limited per policy*	T4534	Limited per policy*	T4535	Limited per policy*
T4543	Limited per policy*
*Any combination of diapers, pull-ups, briefs, or liners limited to a maximum of 300 per month without requiring prior authorization.


Procedure Code	Maximum Limitation	Procedure Code	Maximum Limitation	Procedure Code	Maximum Limitation
A4213	As needed	A4216	As needed	A4217	As needed
A4244	1 per month	A4246	1 per month	A4247	1 per month
A4452	20 per month	A4455	4 per month	A6000	15 per month
A6010	As needed	A6011	As needed	A6021	As needed
A6022	As needed	A6023	As needed	A6024	As needed
A6025	As needed	A6154	As needed	A6197	As needed
A6198	As needed	A6199	As needed	A6200	As needed
A6201	As needed	A6202	As needed	A6203	As needed
A6204	As needed	A6205	As needed	A6210	As needed
A6211	As needed	A6214	As needed	A6215	As needed
A6217	As needed	A6218	As needed	A6219	As needed
A6220	As needed	A6221	As needed	A6228	As needed
A6229	As needed	A6230	As needed	A6234	As needed
A6235	As needed	A6236	As needed	A6238	As needed
A6239	As needed	A6240	As needed	A6241	As needed
A6242	As needed	A6248	As needed	A6250	2 per month
A6251	As needed	A6252	As needed	A6253	As needed
A6254	As needed	A6255	As needed	A6256	As needed
A6257	As needed	A6258	As needed	A6259	As needed
A6260	As needed	A6261	As needed	A6262	As needed
A6403	As needed	A6404	As needed	A6407	As needed
A6410	As needed	A6411	As needed	A6412	As needed
A6441	As needed	A6442	As needed	A6443	As needed
A6444	As needed	A6445	As needed	A6446	As needed
A6447	As needed	A6448	As needed	A6449	As needed
A6450	As needed	A6451	As needed	A6452	As needed
A6453	As needed	A6454	As needed	A6455	As needed
A6456	As needed	A6550	15 per month