Medicaid Denial Chart

DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN
Division of Medicaid Services
F-21042 (03/2017)
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 / Adaptive Aid – Vehicle – SPC 112.57
Item / Date Purchased / Item / Date Purchased
The Arthwriter / Air conditioning (if medically necessary)
Bed shampoo tray / Hand controls
Braille clock / Tie-downs
Button aid / Wheelchair lift
Checking writing guide / Zero-resistance steering wheel
Clothes dryer (front loading, accessible)
Clothes washer (front loading, accessible) / Specialized Medical Supplies – SPC 112.55
Item / Date Purchased
Cutting board—adaptive / Air conditioner (window)
Dishwasher / Air purifier
Door knob extender or levers / Bolsters or bed wedges
Electric shaver / Cold air humidifier
Electric toothbrush and replacement brushes / Dehumidifier
Exercise/fitness equipment
Flashing, signaling devices / Hot water bottle
Foam rubber handle for eating utensils / Medical alert bracelet
Gail belt, Wanderguard / Nicotine patches, Nicorette gum
Jar opener / Nutritional liquid supplement (Ensure, Boost, Carnation, etc.)
Lift chair
Magnifying glass / Scale
Microwave oven / Space heater
One-handed electric can opener / Waterproof vinyl sheeting
Over-the-bed hospital tables / Wheelchair gloves
Pill box / Whirlpool – portable
Portable wheelchair ramp / Whirlpool tub
Rubber stamp w/signature
Standers
Stove knob turner
Talking clock / Communication Aids – SPC 112.47
Talking scale / Item / Date Purchased
Telephone—large button / Answering machine
Telephone—with amplifier / Cellular phone (basic monthly rate)
Telephone—with speaker / Cellular phone
Trays for walkers, standers / Cordless phone
Walker or wheelchair/backpack or basket / Intercom/room monitor (not in substitute care facilities)
Zipper pulls / Interpreter services (either sign or foreign language)
Pocket talkers
SIGNATURE – Care Manager