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TO:     All Providers

RE:      Quarterly DME Updates

Effective June 1, 2025, the Alabama Medicaid Agency (Medicaid) updated the incontinence supply criteria (provided below). 

Medicaid will consider payment for incontinence supplies (diapers OR pullups) when referred as medically necessary with an EPSDT screening AND the following criteria are met:

1. Recipients between the ages of 3 and 20 years old must meet one of the following: 

1. At least 3 years old if non-ambulatory; 

2. OR At least 3 years old if minimally or fully ambulatory AND medically at risk for skin breakdown, which is defined as meeting at least two of the following:

                                        i.         Unable to control bowel or bladder functions;

                                       ii.        Unable to utilize regular toilet facilities due to medical condition;

                                      iii.        Unable to physically turn or reposition self independently;

                                     iv.        Unable to transfer self from bed to chair or wheelchair independently.

3. OR At least 3 years old if minimally or fully ambulatory AND unable to assist in his/her toileting needs due to mental status, a cognitive disability, or a developmental disability.

                                          i.    Documentation must be recipient specific and detailed to include the following:

1. How the cognitive, developmental, or behavioral diagnosis/disability affects or inhibits independent toileting.
2. Documentation of failed caregiver led toilet training OR therapy led toilet training. 

NOTE: Form letters will NOT be accepted for medical necessity documentation. Recipients cannot receive both diapers and pullups in the same benefit period. If there is a current PA for diapers, it must be end-dated prior to submitting a PA for pullups and vice versa. 

Policy questions concerning this ALERT 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.