Free Medicaid Denial Chart - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-21042 (08/2008)

STATE OF WISCONSIN

MEDICAID DENIAL CHART
Name ­ Medicaid Recipient (Last, First, MI) Date of Report

The following item(s) has/have been obtained on behalf of the person named above, and paid for with CIP II, CIP 1A, CIP 1B, or COP-W funding; item(s) is/are not fundable under Medicaid. Note: This is not an all-inclusive list.

Adaptive Aids - SPC 112.99
Item The Arthwriter Bed shampoo tray Braille clock Button aid Checking writing guide Clothes dryer (front loading, accessible) Clothes washer (front loading, accessible) Cutting board--adaptive Dishwasher Door knob extender or levers Electric shaver Electric toothbrush and replacement brushes Flashing, signaling devices Foam rubber handle for eating utensils Gail belt, Wanderguard Jar opener Lift chair Magnifying glass Microwave oven One-handed electric can opener Over-the-bed hospital tables Pill box Portable wheelchair ramp Rubber stamp w/signature Standers Stove knob turner Talking clock Talking scale Telephone--large button Telephone--with amplifier Telephone--with speaker Trays for walkers, standers Walker or wheelchair/backpack or basket Zipper pulls Date Purchased

Adaptive Aid ­ Vehicle ­ SPC 112.57
Item Air conditioning (if medically necessary) Hand controls Tie-downs Wheelchair lift Zero-resistance steering wheel Date Purchased

Specialized Medical Supplies ­ SPC 112.55
Item Air conditioner (window) Air purifier Bolsters or bed wedges Cold air humidifier Dehumidifier Exercise/fitness equipment Hot water bottle Medical alert bracelet Nicotine patches, Nicorette gum Nutritional liquid supplement (Ensure, Boost, Carnation, etc.) Scale Space heater Waterproof vinyl sheeting Wheelchair gloves Whirlpool ­ portable Whirlpool tub Date Purchased

Communication Aids ­ SPC 112.47
Item Answering machine Cellular phone (basic monthly rate) Cellular phone Cordless phone Intercom/room monitor (not in substitute care facilities) Interpreter services (either sign or foreign language) Pocket talkers Date Purchased

SIGNATURE ­ Care Manager