Chapter 3 – Health Care Operations

Policy

• California Correctional Health Care Services (CCHCS) shall provide Durable Medical Equipment (DME) and medical supplies to California Department of Corrections and Rehabilitation (CDCR) patients at no charge and as medically necessary to ensure the patients have equal access to services, programs, or activities.  

• Medically necessary implanted medical devices and dental prosthetic appliances are excluded from this policy.

Purpose

• The purpose of the DME and medical supply policy is to ensure:

• Patient DME needs are properly addressed.

• Institution safety and security are maintained by working with and advising custody staff regarding the distribution and maintenance of DME.

• Efficient use of resources.

• Standardized processes and prescribing practices.

• Availability of necessary DME and medical supplies.

Responsibility

• Statewide

  • CCHCS and CDCR departmental leadership, at all levels of the organization, shall ensure administrative, custodial, and clinical systems are in place and appropriate tools, training, technical assistance, and levels of resources are available so that care teams can successfully implement the DME and Medical Supply policy.

  • The Headquarters DME and Medical Supply Committee (HDMEC) provides statewide oversight and management of systems necessary for implementing this policy, including authorization and maintenance of the Provider Ordered Durable Medical Equipment and Medical Supply Formulary.

  • Business Services, Acquisition Management Section is responsible for and oversees statewide acquisitions for non-Information Technology (non-IT) health care goods and support services, including processing requests for non-IT goods.

  • Information Technology Acquisition Services is responsible for overseeing IT statewide acquisitions, including processing requests for IT health care goods.

• Regional

  • The Regional Health Care Executive and Associate Director are responsible for this procedure at the subset of institutions within an assigned region.

• Institution

  • The Chief Executive Officer (CEO) and Warden, or designees, have overall responsibility for adherence to this policy at the institution.

  • The Chief Medical Executive (CME), or designee, is responsible for the overall medical management of patients and ensures resources are available to meet the needs of the population.

  • Health care leadership is responsible for establishing local operating procedures (LOPs) to implement the statewide procedure, including authorization, review, acquisition request submission, goods receipt, and issuance of DME.

Procedure

• HDMEC

  • The HDMEC structure and proceedings shall follow the policy outlined in the Health Care Department Operations Manual (HCDOM), Section 1.2.19, Headquarters Durable Medical Equipment and Supply Committee and Interdisciplinary Team.

• Medical Equipment and Supply Interdisciplinary Team

  • The Medical Equipment and Supply Interdisciplinary Team oversees DME and medical supply management from the headquarters level as outlined in the HCDOM, Section 1.2.19, Headquarters Durable Medical Equipment and Supply Committee and Interdisciplinary Team.

• Acquisition Management Section

  • Acquisition Services shall process requests for all non-IT health care support goods and services including:

    • Institutional and headquarters non-IT health care support procurement requests intended for medical purposes.

    • Institutional and headquarters non-IT health care support services contracts.

  • Enterprise Asset Management shall develop policies and procedures for medical supplies and equipment including:

    • Materials management functions involving inventory, receipt, storage, and issuance of materials to the clinic.

    • Data management tasks for approved medical supplies and DME on the Standard Medical Supply and Durable Medical Equipment List.

• Provider Ordered Durable Medical Equipment and Medical Supply Formulary

  • The Durable Medical Equipment and Medical Supply Committees shall address the following whenever applicable to the formulary:

    • Item name

    • Variations.

    • Associated supplies.

    • Indications – medical necessity for variations or associated supplies, if applicable.

    • Prescription requirement versus authorization.

    • Reusable or single patient use.

    • Anticipated annual usage and cost.

    • Clinical references.

  • Process for review and change of formulary

    • Review the formulary annually and as needed.

    • Items may be added, deleted, or updated at any time by actions of the HDMEC.

    • The formulary shall be maintained electronically.

    • The formulary shall be made available to patients in prison law libraries.

    • Institutions may request that the HDMEC add, delete, or update items as outlined in the HCDOM, Section 1.2.19, Headquarters Durable Medical Equipment and Supply Committee and Interdisciplinary Team.

    • If a new item requires security consideration, HDMEC shall send a request for review to the CCHCS Corrections Services Deputy Director’s office. The Health Care Policy and Litigation Support Unit shall review internally and may request additional input from Division of Adult Institutions Office of Policy Standardization.

  • Formulary request process

    • The provider shall complete the DME or medical supply order in the Electronic Health Record System (EHRS).  The order shall include priority and, if applicable, type, size, quantity, duration, and frequency of use.

  • Nonformulary request process for non-emergent DME

    • The nonformulary request process shall begin with the submission of a Health Care Services Physician electronic Request for Services.

    • The CME, or designee, shall review nonformulary requests.

      • The requests shall be reviewed within the same timeframes as a non-DME Request For Service.

      • The reason for approval or denial shall be documented in the health record.

      • The CME, or designee, shall inform the requesting provider of the disposition through the health record.

      • If a request is not approved, the provider shall document consideration of alternatives and any action taken. A provider may appeal a denial to the HDMEC as outlined in the HCDOM, Section 1.2.19, Headquarters Durable Medical Equipment and Supply Committee and Interdisciplinary Team.

    • Notification of nonformulary DME orders shall be labeled as such and routed to procurement on stand‑alone purchase orders for tracking purposes.

• Durable Medical Equipment and Medical Supplies

  • DME and medical supplies shall be distributed by health care staff based on medical necessity as defined in the Provider Ordered Durable Medical Equipment and Medical Supply Formulary then in effect unless approved through the nonformulary request process as outlined in Section (d)(4)(D).

  • Personal property items permitted by the CDCR Department Operations Manual (DOM) shall not be considered DME or medical supplies and are not prescribed by health care staff.

  • Hygiene supplies normally provided by custody, as defined in the CDCR DOM shall not be considered medical supplies or DME and are not prescribed by health care staff.  Hygiene supplies do not need consultation or approval from health care staff. 

  • Incontinence supplies shall be accessible for patients whenever they are needed.  Upon completion of medical evaluations, Primary Care Providers (PCPs) shall prescribe incontinence supplies as necessary without restrictions should the patients need adjustments to quantities needed. 

  • Disability (mobility, hearing, vision) identification vests are miscellaneous supplies that are included as a standard item of DME.  Disability identification vests shall be prescribed, purchased, and issued by health care staff.

  • Standard issue clothing and bedding items such as mattresses and pillows are not classified as either medical supplies or DME.  Patients should request these items using existing local procedure.

• Procurement and Purchasing

  • DME purchases shall be processed in accordance with standard state procurement processes.

  • Patients shall not be financially responsible for the cost to purchase medically necessary DME.  This does not preclude a patient from financial responsibility for damage pursuant to Section (d)(15)(B)2. and CCR, Title 15, Section 3011.

  • Patients shall not have the option to order DME from third-party vendors with the exception of prescription eyeglasses as follows:

    • Patients with an eyeglass prescription documented in the last two years may purchase or have their family or friends purchase and mail prescription eyeglasses to the institution directly, or via a third-party vendor.

      • CDCR and CCHCS does not assume any liability for repairs or damage to the eyeglasses.

      • If the prescription eyeglasses are deemed to have been damaged by staff or another patient, the only option for replacement by CDCR and CCHCS shall be with the currently approved Prison Industry Authority eyeglasses, and the issuance of reading glasses or sunglasses through the canteens at no charge to the patient. any liability for repairs or damage to the eyeglasses.

    • Patients, or their family and friends, may at their expense mail replacement prescription eyeglasses directly to the institution, or via a third-party vendor.

      • CDCR and CCHCS shall not be liable for any replacement costs associated with the replacement.

      • CDCR and CCHCS staff shall not provide any fitting or adjustment services for any eyeglasses purchased from a third-party vendor or mailed in by family or friends.

• Storage of DME and Medical Supplies

  • Institution health care management shall establish and maintain a process to manage DME and medical supply inventory which shall include, but not be limited to:

  • Assigning responsibility for inventory oversight.

  • Centralizing DME and medical supply storage.

  • Limiting access to supply inventory.

  • Rotating stock kept in storage.

  • Monitoring supply usage in the clinics to prevent materials from expiring.

  • Purchasing supplies in the most economical manner available which shall include, but is not limited to, use of the Provider Ordered Durable Medical Equipment and Medical Supply Formulary and the Kanban ordering system.

  • Adjusting purchasing practices to minimize waste.

• Delivery of DME and Medical Supplies

  • Timeframes for delivery of prescribed DME and medical supplies shall be entered as follows, based on availability of the item:

    • Same day (DME and medical supplies available in the clinic shall be provided to the patient prior to leaving the clinic e.g., wheelchairs, walkers, canes, crutches, and disability identification vests).

    • Expedited – Within five calendar days (DME and medical supplies in stock at the medical warehouse, but unavailable same day of appointment).

    • High Priority – Within 14 calendar days (DME and medical supplies are unavailable at the institution and must be ordered through a vendor).

    • Routine – Within 90 calendar days (DME and medical supplies are unavailable at the institution and have a long lead time for delivery).

    • For patients returning to institutions from hospitals, medically necessary DME shall be available upon arrival at the institution. Health care staff shall follow established LOPs.

  • The CEO shall designate a staff person at their respective institution responsible for tracking DME issuance.

• Patient Arrival to CDCR with DME from outside of CDCR

  • All DME arriving with a patient to an institution shall be subject to inspection, review, and acceptance by custody for safety and security concerns and by health care staff for medical necessity.

  • If custody staff determines a safety or security concern with a particular item of DME either generally or in possession of a particular patient, the CME, or designee, shall be consulted immediately to determine the appropriate action to accommodate the patient’s needs.

    • Accommodation may include modifying the DME or providing a suitable formulary replacement item when medically necessary at CDCR’s expense.

    • Only under exceptional circumstances will a medically necessary approved DME be removed, and an alternate means provided.  A subsequent written report memorializing the removal action shall be provided by custody personnel.  All such circumstances shall be appropriately documented in the health record.

    • The provider shall examine the patient to determine the medical necessity of DME arriving with the patient.

      • If medically necessary, the provider shall place the appropriate DME order in the EHRS.

      • Documentation in the EHRS indicating the disposition of the DME, per the PCP order, shall occur by clinical staff using the CDCR 7536, Durable Medical Equipment and Medical Supply Receipt.

• Patient Transfer with DME within CDCR

  • Patients transferred from one CDCR institution to another shall be allowed to maintain possession of DME or medical supplies or both.

  • Prior to transfer, the Receiving and Release (R&R) Registered Nurse (RN) shall review the patient’s current CDCR 7536 to ensure accuracy and update if necessary to reflect all DME is in the patient’s possession and documented in the health record.  A new CDCR 7536 shall be generated if not documented in the health record.

  • At the receiving institution, all previously prescribed DME and medical supplies shall continue to be provided.

  • At the receiving institution, the R&R RN shall be responsible for ensuring that patients are provided with prescribed DME or medical supplies or both upon arrival, if not in the patient’s possession.

  • The receiving institution R&R RN shall review the patient’s current CDCR 7536 to ensure accuracy and update if necessary to reflect all DME is in the patient’s possession and documented in the health record.  A new CDCR 7536 shall be generated if not documented in the health record.

  • Pre-ordered DME received by the patient’s previous institution after transferring shall be forwarded to the receiving institution (e.g., shoes, orthotics, and prescription eyeglasses).

• Inspection and Inventory

  • DME is subject to inspection to ensure it is functional and in working order.

  • All DME may be inspected by custody staff according to the current CDCR DOM.

  • Custody staff shall conduct and log safety and security inspections on all wheelchairs at least monthly.  This process shall be defined in the LOP. Repair logs shall be submitted to the ADA Coordinator and Chief Support Executive to ensure follow up with health care.

  • Custody shall document the possession and condition of DME on a Strategic Offenders Management System automated form ISST200 whenever there is a need to inventory property (e.g., restricted housing placement, inter-institution transfer, out-to-medical, out-to-court, extradition).

  • All DME shall be inscribed with the patient’s CDCR number.

• Temporary Issuance of DME

  • Patients may receive temporary DME when:

    • The permanent DME is not yet available for use (e.g., ordered and not delivered; requiring time for preparation, construction, or fabrication) and an interim accommodation with DME is required.

    • The need for DME is time-limited due to the nature of the condition requiring the need for DME (e.g., crutches during a healing fracture of the leg).

    • Permanent DME is being repaired or maintained.

  • CCHCS property temporarily issued to a patient must contain a permanent inscription or engraving of the serialized property number on metal or wood. Property number shall be written in indelible marker on soft materials.

  • When the indication for temporary DME no longer exists, the DME shall be returned to CDCR and inspected to ensure it is in working condition with reasonable wear and tear.

• Patient Receipt and Refusal of DME and Medical Supplies

  • Receipt or refusal of DME and medical supplies shall be documented on a CDCR 7536 and shall be included in the health record. 

  • A separate copy of a CDCR 7536 shall be provided to the patient for each DME or medical supply provided.

  • If a patient refuses DME, the staff that delivers the DME shall make a referral to the requesting provider for the patient to be seen to determine and provide an appropriate interim accommodation if needed.

  • Refusal of DME or medical supplies shall also be documented on a CDC 7225, Refusal of Examination and/or Treatment, at the time of the clinical encounter.  The CDC 7225 shall reference the CDCR 7536 and shall be included in the health record.

  • All patients who have been issued DME or medical supplies shall be advised to submit a CDCR 7362, Health Care Services Request Form, to discuss DME or medical supply issues.

• Rescinding and Discontinuance of DME and Medical Supplies

  • If at any time the PCP determines a DME item is no longer medically necessary, the PCP shall discontinue the order and update the health record.

    • Nursing staff shall collect the DME from the patient and update the CDCR 7536.

    • If the patient did not bring the DME to the clinic or refuses to relinquish the DME, health care staff shall notify custody staff of the rescission of the DME, and custody shall collect the DME.

  • For an item no longer part of the Provider Ordered Durable Medical Equipment and Medical Supply Formulary, if it is no longer determined to be medically necessary, health care shall discontinue the order and remove the item from the CDCR 7536.  Patients may be allowed to retain the item on a case-by-case basis through the reasonable accommodation process.

• Defective or Damaged DME

  • New DME received from a manufacturer that is found to be defective shall be returned to the manufacturer for replacement or repair in accordance with the manufacturer’s warranty.

  • Upon discovery of damage to DME, the following shall apply:

    • Health care staff shall determine whether DME should be repaired or replaced or submit a CDCR 7362 for evaluation.

    • All patients shall be financially responsible for damage caused by personal neglect, misuse, or intentional destruction.

  • The incarcerated person purposely causing damage to the DME shall be held responsible according to the established process regarding the destruction of property.

  • CDCR and CCHCS shall accept liability for the loss or destruction of DME resulting from employee action as established in departmental policy and procedure.

• Maintenance of DME

  • It is the joint responsibility of CDCR, CCHCS, and the patient to maintain all DME in good repair and operation.

  • The patient may notify health care staff and custody staff verbally of concerns related to DME maintenance or submit a CDCR 7362.

  • Once the need for repair or replacement is verified and it is determined that the DME cannot be repaired on-site, staff shall:

    • Issue appropriate replacement or temporary DME, or

    • Provide another adequate accommodation.

    • If the patient’s DME is sent out for repair, staff shall document and track the repair on the CDCR 7534, Durable Medical Equipment Maintenance Log.

  • CCHCS shall maintain the appropriate service contracts for DME maintenance, including wheelchairs and walkers.

• Change In Security Setting, Patient Misuse and/or Diversion

  • Patients transferred or assigned to higher levels of security within the institution shall be allowed to maintain possession of DME or medical supplies or both.

  • DME shall be removed from a patient only to ensure the safety of persons, the security of the institution, or to assist in an investigation and only when supported by documented evidence.  If the DME presents a direct and immediate threat to safety and security, the DME may be removed from a patient immediately by any custody staff.

    • DME shall only be removed for as long as the DME continues to pose a direct threat to safety and security.

    • DME shall not be removed from a patient because of the acts of another incarcerated person.

    • The decision to remove DME from a patient admitted to the Mental Health Crisis Bed shall include the psychiatrist in accordance with the Mental Health Services Delivery System Program Guide.

  • When DME is taken away from a patient for reasons of safety and security:

    • The senior custody officer in charge shall immediately consult the CME, or designee, regarding the patient’s need for the DME and reasonable alternative in-cell accommodations.  The CME shall inform the CEO of this action.

    • Health care staff shall review the health record to determine the temporary alternative to the DME and advise custody staff.

    • The senior custody officer in charge shall inform the Warden, or designee, of the determination and the alternative means to accommodate the patient.

  • If custody staff decides to retain the DME, it shall be stored in a designated location in the unit and provided to the patient if needed when released from their cell for yard, escorts, visits, etc.

    • During the period of alternative in-cell accommodation, health care staff shall regularly observe the patient’s health condition and document observed changes in the health record.

    • If evidence of a deteriorating health condition is observed, health care staff shall immediately advise custody staff of a need for medically necessary changes to the in-cell care.

    • Alternative DME or removal of DME shall be documented in the health record.

    • If staff witness apparent misuse or diversion of a DME item, they may report their observations to health care staff in writing (e.g., health record or CDCR 128-B, General Chrono).  The PCP may consider this information when determining the ongoing medical necessity for the DME.

• Patient Release or Parole

  • CHCS shall provide 30 days of prescribed medical supplies upon release or parole.  Prescribed medical supplies include, but are not limited to:

    • Glucometer supplies.

    • Tracheostomy supplies.

    • Colostomy supplies.

    • Urinary catheters.

    • Material for dressing changes.

    • CPAP supplies.

    • Incontinence supplies.

    • Contact lens supplies.

  • DME shall accompany the patient upon release or parole unless a PCP determines at the time of the release or parole that the DME is no longer medically necessary. The medical warehouse shall be informed of temporary DME issued to a patient upon release.

  • The R&R RN shall be responsible for ensuring that patients are provided with prescribed DME or medical supplies, if not in the patient’s possession.

  • Prior to release or parole, the R&R RN shall review the patient’s current CDCR 7536 to ensure accuracy and that all accepted DME or medical supplies are in the patient’s possession and are documented in the health record. The R&R RN shall notify custody staff of any missing DME that needs to be retrieved.  A new CDCR 7536 shall be generated to document all DME or medical supplies accepted or refused.

  • Pre-ordered DME received by the institution after the patient is paroled shall be forwarded to the parole unit supervising the supervised person.  CDCR shall make every reasonable attempt to deliver pre-ordered DME to patients who have been released from CDCR custody.

• Transfer to County Facilities or Other Outside Facilities

  • Medically necessary DME shall accompany patients when transferred to any outside facility (e.g., out-to-court transfers) for any reason and shall accompany the patients upon return. Upon return, DME orders shall be reconciled and items issued as needed, and a CDCR 7536 shall be completed.

• Institution Local Operating Procedure

  • Institutions shall establish LOPs to implement the statewide procedure. Required elements of the LOPs are provided in Appendix 1.

Policy

• The California Department of Corrections and Rehabilitation (CDCR) and California Correctional Health Care Services (CCHCS) shall provide medically necessary accommodations to patients to ensure equal access to prison services, programs, and activities. CCHCS shall maintain a formulary that contains statewide guidance for certain types of accommodations. Accommodations not listed in the formulary, or formulary accommodations based on medical necessity, may be requested via the nonformulary accommodation process, as outlined in Section (d)(4)(M).

• Durable medical equipment provided as a part of an accommodation is addressed in Section (d)(4).

Purpose

• To provide patients standardized temporary or permanent medically necessary accommodations to ensure equal access to prison services, programs, and activities and to ensure continuity of all medically necessary accommodations.

Responsibility

• The Deputy Director (DD), Medical Services, is responsible for the statewide policy and oversight.

• The Regional Deputy Medical Executives (DMEs) are responsible for implementation of the procedure at each of their respective institutions.

• The Chief Executive Officer, Warden, and Chief Medical Executive (CME) at each institution are jointly responsible for the implementation of this policy and procedure.

Procedure

• Overview

  • The provider shall order an accommodation for a patient when medically necessary or to ensure the patient has equal access to prison services, programs, and activities.  Accommodation decisions shall be based on guidance provided in the Comprehensive Accommodation Formulary and clinical judgment, or may be ordered as a nonformulary accommodation as medically necessary.

• Applicability

  • This procedure applies to accommodations provided to outpatients in CDCR institutions. This procedure does not apply to durable medical equipment or medical supplies which are covered in the Health Care Department Operations Manual (HCDOM), Section 3.6.1, Durable Medical Equipment and Medical Supply.

• Comprehensive Accommodation Formulary

  • A committee at CCHCS Headquarters shall be designated to develop, revise, and maintain the Comprehensive Accommodation Formulary.

    • Membership

      • The committee shall consist of members designated by the DD, Medical Services, or designee.

      • At least two members shall be physicians.

      • Membership may include executive or managerial representation from Medical Services, Nursing Services, Mental Health program, Health Care Correspondence and Appeals Branch, Dental Services, and other health care and custody staff.

      • The Headquarters-designated committee shall meet as directed by the DD, Medical Services, but at least annually.

      • Review of the Comprehensive Accommodation Formulary will be completed on an annual basis or more often if necessary. Updates will be issued to institution and contract staff.

  • The Comprehensive Accommodation Formulary shall contain criteria for the issuance of accommodations.  The formulary shall address, as relevant, the following:

    • Accommodation type

    • Indications and establishment of medical necessity

    • Security considerations

    • Clinical references

  • The following are not medically necessary accommodations and will not be ordered by health care staff:

    • Bedding:

      • Standard-issued custody mattresses

      • Extra pillows

      • Blankets

    • Housing, except for control of infectious disease or for mental health reasons as recommended by a Mental Health Interdisciplinary Treatment Team:

      • Single cells

      • Cell housing

      • Dormitory housing

    • Clothing:

      • Shoes, including tennis shoes

      • Specific sizes of clothing

      • Thermal underwear

      • Hats

      • Long-sleeved shirts

    • Shower chairs

    • Extra toilet paper

• Request or Recommendation for an Accommodation

  • Patients shall request an accommodation by using the processes for requesting health care services or the process for requesting a disability accommodation.

  • A provider may initiate a request for an accommodation based on medical necessity or to ensure a patient has equal access to prison services, programs, and activities.

  • Custody or other staff may refer the patient for consideration of an accommodation if it appears an accommodation may be needed.  The process for this referral shall be the same as the process to refer a patient for any other health care need.

  • Specialty consultants may provide recommendations for an accommodation through consultation reports. Such a recommendation shall be evaluated by the primary care provider as part of the review of specialist recommendations in accordance with the HCDOM.

  • When an accommodation is requested or recommended, the provider shall assess the need for the accommodation.

    • The assessment may include an evaluation of the patient’s ability to perform job related functions, activities of daily living, and any limitations or restrictions thereof.

    • A duplicate request from any source, made within 90 days of an original request, may be denied if there is no change in the patient’s clinical condition.

  • The provider shall document the assessment in the health record as follows:

    • Using the guidance in the Comprehensive Accommodation Formulary to record whether or not the accommodation is indicated and why, or stating why a nonformulary request is medically necessary or needed to ensure equal access to prison services, programs, and activities.

    • Indicating whether the accommodation is temporary or permanent.

  • The ordering provider shall electronically complete the required forms for the accommodation including the following:

    • Medical Classification Chrono

    • Face Sheet for the Combined Comprehensive Accommodation Chrono and Disability Placement Program Verification eForm

  • Accommodations designated as permanent do not require further review or renewal.  The accommodation may be revised or removed by the provider as indicated by the patient’s status.

    • Any new Comprehensive Accommodation Chrono replaces in its entirety any prior Comprehensive Accommodation Chrono and must include all current accommodations.  The provider is responsible for reviewing the current accommodations and for ensuring inclusion as appropriate.

    • Patients may be referred by staff for provider re-evaluation of the need for an accommodation, if observation suggests that the accommodation may need to be modified or removed.

    • The accommodation shall remain valid and in force unless a new Comprehensive Accommodation Chrono is generated indicating a new provider order.

    • The accommodation may be updated or rescinded at any time, even if previously written as permanent.

  • Temporary accommodations shall remain in force until the documented timeframe has expired.

  • The accommodation remains valid and in force, if clinically indicated, even if the patient transfers to a different institution.

  • All accommodation chronos shall be filed in the health record.  A copy of the accommodation chrono shall be placed in the patient’s Central File and a copy shall be provided to the patient.

  • An electronic copy of all accommodation chronos shall be provided automatically via email from the eForm application to the following staff:

    • Americans with Disabilities Act Coordinator

    • Class Action Management Unit Correctional Counselor II

    • Classification and Parole Representative

    • Assistant Classification and Parole Representative

  • Nonformulary request process

    • Providers may request a nonformulary accommodation by indicating the medically necessary accommodation(s) in the appropriate section on the Comprehensive Accommodation Chrono. The provider shall transmit the Comprehensive Accommodation Chrono to the CME or Chief Physician and Surgeon for review and shall include necessary documentation to justify the nonformulary accommodation.

    • The CME, or designee, shall review and approve or disapprove the request(s) and document the reason for the approval or disapproval in the patient’s health record.

    • A provider may appeal the denial of a nonformulary accommodation to the CME or Regional DME.