CSHCN 2008 >15.3 Benefits and Limitations

15.3 Benefits and Limitations

The CSHCN Services Program provides benefits for expendable medical supplies for eligible clients. A medical supply is defined as an item necessary to carry out a medical procedure or to maintain the client's health at home. Most medical supplies are expendable, meaning that they are either not reusable or usable only for a short time and are discarded after use.

Supplies are a benefit only for those clients residing at home.

Specific procedure or diagnosis codes related to program benefits may be listed in the sections that follow. These listings are intended to provide helpful information, but should not be considered all-inclusive. From time to time, codes are added, deleted, or revised. Benefit and coding information is updated in the CSHCN Services Program Provider Bulletin.

Some expendable medical supplies are limited in the amounts allowed per month. If claims are denied as exceeding these limits, providers may submit documentation of medical need for those clients who require amounts above the usual limits. The following tables provide listings of these supplies and limitation amounts.

Incontinence Supplies


Procedure Code	Maximum Limitation	Procedure Code	Maximum Limitation	Procedure Code	Maximum Limitation
9-A4310	2 per month	9-A4311	2 per month	9-A4312	2 per month
9-A4313	2 per month	9-A4314	2 per month	9-A4315	2 per month
9-A4316	2 per month	9-A4320	2 per month	9-A4326	31 per month
9-A4327	4 per month	9-A4328	4 per month	9-A4330	As needed
9-A4335	2 per month	9-A4338	2 per month	9-A4340	2 per month
9-A4344	2 per month	9-A4346	2 per month	9-A4349	31 per month
9-A4351	120 per month	9-A4352	120 per month	9-A4353	120 per month
9-A4354	2 per month	9-A4355	2 per month	9-A4356	2 per month
9-A4357	2 per month	9-A4358	2 per month	9-A4361	As needed
9-A4362	As needed	9-A4363	As needed	9-A4364	As needed
9-A4365	1 per month	9-A4367	As needed	9-A4368	As needed
9-A4371	As needed	9-A4372	As needed	9-A4373	As needed
9-A4375	As needed	9-A4376	As needed	9-A4377	As needed
9-A4378	As needed	9-A4379	As needed	9-A4380	As needed
9-A4381	As needed	9-A4382	As needed	9-A4383	As needed
9-A4384	As needed	9-A4385	As needed	9-A4387	As needed
9-A4388	As needed	9-A4389	As needed	9-A4390	As needed
9-A4391	As needed	9-A4392	As needed	9-A4393	As needed
9-A4394	As needed	9-A4395	As needed	9-A4396	As needed
9-A4397	As needed	9-A4398	As needed	9-A4399	As needed
9-A4400	As needed	9-A4402	4 per month	9-A4404	As needed
9-A4405	As needed	9-A4406	As needed	9-A4407	As needed
9-A4408	As needed	9-A4409	As needed	9-A4410	As needed
9-A4411	As needed	9-A4412	As needed	9-A4413	As needed
9-A4414	As needed	9-A4415	As needed	9-A4421	As needed
9-A4422	As needed	9-A4455	4 per month	9-A4554	150 per month
9-A4927	1 per month	9-A5051	As needed	9-A5052	As needed
9-A5053	As needed	9-A5054	As needed	9-A5055	As needed
9-A5061	As needed	9-A5062	As needed	9-A5063	As needed
9-A5071	As needed	9-A5072	As needed	9-A5073	As needed
9-A5081	As needed	9-A5082	As needed	9-A5093	As needed
9-A5102	2 per month	9-A5105	4 per year	9-A5112	2 per month
9-A5113	2 per month	9-A5114	2 per month	9-A5120	1 per month
9-A5121	As needed	9-A5122	As needed	9-A5126	As needed
9-A5131	1 per month	9-A5200	2 per month	9-A6250	2 per month
J-E0163	1 per 5 years	J-E0163-TG	1 per 5 years	J-E0165	1 per 5 years
J-E0165-TG	1 per 5 years	J-E0167	1 per year	J-E0168	1 per 5 years
J-E0168-TF	1 per 5 years	J-E0168-TG	1 per 5 years	J-E0175	1 per 5 years
J-E0275	2 per year	J-E0276	2 per year	J-E0325	2 per year
J-E0326	2 per year	9-T4521	Limited per policy*	9-T4522	Limited per policy*
9-T4523	Limited per policy*	9-T4524	Limited per policy*	9-T4525	Limited per policy*
9-T4526	Limited per policy*	9-T4527	Limited per policy*	9-T4528	Limited per policy*
9-T4529	Limited per policy*	9-T4530	Limited per policy*	9-T4531	Limited per policy*
9-T4532	Limited per policy*	9-T4533	Limited per policy*	9-T4534	Limited per policy*
9-T4535	Limited per policy*	9-T4543	Limited per policy*
*Any combination of diapers, pull-ups, briefs, underpads, or liners limited to a maximum of 300 per month without requiring authorization.

Respiratory Supplies


Procedure Code	Maximum Limitation	Procedure Code	Maximum Limitation	Procedure Code	Maximum Limitation
9-A4481	31 per month	9-A4483	1 per day	9-A4605	10 per month
9-A4606	4 per month	9-A4611	1 per 5 years	9-A4612	1 per 5 years
9-A4613	1 per 5 years	9-A4614	2 per year	9-A4615	1 per 2 weeks
9-A4616	1 per 3 months	9-A4617	2 per month	9-A4618	4 per month
9-A4623	1 per month	9-A4624	90 per month	9-A4627	1 per 6 months
9-A4628	2 per month	9-A4629	31 per month	9-A7000	4 per month
9-A7002	8 per month	9-A7003	2 per month	9-A7004	2 per month
9-A7006	2 per month	9-A7007	2 per month	9-A7009	Every two years
9-A7011	1 per 6 months	9-A7013	1 per month	9-A7014	1 per year
9-A7015	2 per month	9-A7016	2 per month	9-A7018	4 per month
9-A7026	2 per year	9-A7034	1 per 3 months	9-A7035	1 per 6 months
9-A7037	1 per month	9-A7038	1 per 6 months	9-A7520	Limited per policy
9-A7521	Limited per policy	9-A7522	Limited per policy	9-A7523	Limited per policy
9-A7525	Limited per policy	9-A7526	Limited per policy	9-A9900	1 per month
L-E0424	1 per month	L-E0431	1 per month	L-E0434	1 per month
L-E0439	1 per month	L-E0441	1 per month	L-E0442	1 per month
L-E0443	1 per month	L-E0444	1 per month	L-E0450	1 per month
J-E0457	1 per 5 years	L-E0457	1 per month	J-E0459	1 per lifetime
L-E0459	1 per month	L-E0460	1 per month	L-E0463	1 per month
L-E0464	1 per month	J-E0470	1 per 5 years	L-E0470	1 per month
L-E0471	1 per month	L-E0472	1 per month	J-E0480	1 per 5 years
L-E0480	1 per month	L-E0481	1 per month	L-E0482	1 per month
J-E0483	1 per lifetime	L-E0483	1 per month	L-E0500	4 per lifetime
J-E0561	1 per 5 years	L-E0561	1 per month	J-E0562	1 per 5 years
L-E0562	1 per month	J-E0565	1 per 5 years	L-E0565	1 per month
J-E0570	1 per 5 years	J-E0575	1 per 5 years	J-E0600	1 per 5 years
J-E0601	1 per 5 years	L-E0601	1 per month	J-E1353	1 per year
L-E1399	Limited by policy	9-S8101	2 per month	J-S8189	Limited per policy

Wound Care Supplies


Procedure Code	Maximum Limits	Procedure Code	Maximum Limits	Procedure Code	Maximum Limits
9-A4213	As needed	9-A4216	As needed	9-A4217	As needed
9-A4244	1 per month	9-A4246	1 per month	9-A4247	1 per month
9-A4452	20 per month	9-A4455	4 per month	9-A6000	15 per month
9-A6010	As needed	9-A6011	As needed	9-A6025	As needed
9-A6154	As needed	9-A6197	As needed	9-A6198	As needed
9-A6199	As needed	9-A6200	As needed	9-A6201	As needed
9-A6202	As needed	9-A6203	As needed	9-A6204	As needed
9-A6205	As needed	9-A6210	As needed	9-A6211	As needed
9-A6214	As needed	9-A6215	As needed	9-A6217	As needed
9-A6218	As needed	9-A6219	As needed	9-A6220	As needed
9-A6221	As needed	9-A6228	As needed	9-A6229	As needed
9-A6230	As needed	9-A6234	As needed	9-A6235	As needed
9-A6236	As needed	9-A6238	As needed	9-A6239	As needed
9-A6240	As needed	9-A6241	As needed	9-A6242	As needed
9-A6248	As needed	9-A6251	As needed	9-A6252	As needed
9-A6253	As needed	9-A6254	As needed	9-A6255	As needed
9-A6256	As needed	9-A6257	As needed	9-A6258	As needed
9-A6259	As needed	9-A6260	As needed	9-A6261	As needed
9-A6262	As needed	9-A6403	As needed	9-A6404	As needed
9-A6407	As needed	9-A6410	As needed	9-A6411	As needed
9-A6412	As needed	9-A6441	As needed	9-A6442	As needed
9-A6443	As needed	9-A6444	As needed	9-A6445	As needed
9-A6446	As needed	9-A6447	As needed	9-A6448	As needed
9-A6449	As needed	9-A6450	As needed	9-A6451	As needed
9-A6452	As needed	9-A6453	As needed	9-A6454	As needed
9-A6455	As needed	9-A6456	As needed	9-A6550	15 per month