OAR 410-122-0080
Conditions of Coverage, Limitations, and Restrictions

(1) The Division may pay for durable medical equipment, prosthetics, orthotics and medical supplies (DMEPOS) when the item meets all the criteria in this rule, including all of the following conditions. The item:

(a) Is approved for marketing and registered or listed as a medical device by the Food and Drug Administration (FDA) and is otherwise generally considered to be safe and effective for the intended purpose. In the event of delay in FDA approval and registration, the Division shall review purchase options on a case-by-case basis;

(b) Is reasonable and medically appropriate for the client;

(d) Is generally not useful to an individual in the absence of medical disability, illness, or injury;

(e) Is suitable for use in a client’s home or any non-institutional setting in which normal life activities take place;

(f) Specifically for durable medical equipment can withstand repeated use and can be reusable or removable;

(g) Meets the coverage criteria as specified in this division and subject to service limitations of the Division rules;

(h) Is requested in relation to a diagnosis and treatment pair that is above the funding line and consistent with treatment guidelines on the Health Evidence Review Commission’s (HERC) Prioritized List of Health Services (Prioritized List of Health Services or List) found in OAR 410-141-0520 and not otherwise excluded under OAR 410-141-0500;

(i) Is included in the Oregon Health Plan (OHP) client’s benefit package of covered services; and

(j) Is the least costly, medically appropriate item that meets the medical needs of the client.

(2) Conditions for Medicare-Medicaid Services:

(a) If Medicare is the primary payer and Medicare denies payment, an appeal to Medicare must be filed timely prior to submitting the claim to the Division for payment. If Medicare denies payment based on failure to submit a timely appeal, the Division may reduce any amount the Division determines could have been paid by Medicare;

(b) If Medicare denies payment on appeal, the Division shall apply DMEPOS coverage criteria in this rule to determine whether the item or service is covered under the OHP.

(3) The Division may not cover DMEPOS items when the item or the use of the item is:

(a) Not primarily medical in nature;

(b) For personal comfort or convenience of the client or caregiver;

(d) Not therapeutic or diagnostic in nature;

(e) Used for precautionary reasons (e.g., pressure-reducing support surface for prevention of decubitus ulcers);

(f) Inappropriate for client use in the home or non-institutional setting (e.g., institutional equipment like an oscillating bed);

(g) For a purpose where the medical effectiveness is not supported by evidence-based clinical practice guidelines; or

(h) Reimbursed as part of the bundled rate in a nursing facility as described in OAR 411-070-0085 (Bundled Rate) or as part of a home and community-based care waiver service or by any other public, community, or third party resource.

(4) Codes that are identified in these rules or in fee schedules are provided as a mechanism to facilitate payment for covered items and supplies consistent with OAR 410-122-0186 (Payment Methodology), but codes do not determine coverage. If prior authorization is required, the request for reimbursement shall document that prior authorization was obtained in compliance with the rules in this division.

(5) DMEPOS providers shall have documentation on file that supports coverage criteria are met.

(6) Billing records shall demonstrate that the provider has not exceeded any limitations and restrictions in the DMEPOS rules. The Division may require additional claim information from the provider consistent with program integrity review processes.

(7) Documentation described in sections (4), (5), and (6) above shall be made available to the Division upon request.

(8) To identify non-covered items at a code level, providers can refer to the Division fee schedule, subject to the limitation that fee schedules and codes do not determine coverage and are solely provided as a mechanism to facilitate payment for covered services and supplies consistent with OAR 410-122-0186 (Payment Methodology). If an item or supply is not covered for an OHP client in accordance with these rules, there is no basis for payment regardless of whether there is a code for the item or supply on the fee schedule.

(9) Some benefit packages do not cover equipment and supplies (see OAR 410-120-1210 (Medical Assistance Benefit Packages and Delivery System), Medical Assistance Benefit Packages and Delivery System).

(10) Buy-ups are prohibited. Advanced Beneficiary Notices (ABN) constitute a buy-up and is prohibited. Refer to the Division General Rules (chapter 410, division 120) for specific rules on buying up.

(11) Equipment purchased by the Division for a client becomes the property of the client.

(12) Rental charges starting with the initial date of service, regardless of payer, apply to the purchase price.

(13) A provider who supplies rented equipment shall continue furnishing the same item throughout the entire rental period, except under documented reasonable circumstances.

(14) Before renting, providers must consider purchase for long-term requirements.

(15) The Division may not pay DMEPOS providers for medical supplies separately while a client is under a home health plan of care and covered home health care services.

(16) The Division may not pay DMEPOS providers for medical supplies separately while a client is under a hospice plan of care where the supplies are included as part of the written plan of care and for which payment may otherwise be made by Medicare, the Division, or other carrier.

(17) Separate payment may not be made to DMEPOS providers for equipment and medical supplies provided to a client when the cost of the items is already included in the capitated (per diem) rate paid to a facility or organization.

(18) Certain specified medical equipment and supplies require a face-to-face examination as described in these rules consistent with federal regulations at 42 CFR 440.70. See OAR 410-122-0090 (Face-to-Face Encounter Requirements (for Fee-For-Service Clients)) for the face-to-face requirements.

(19) Non-contiguous out-of-state DMEPOS providers may seek Medicaid payment only under the following circumstances:

(a) Medicare/Medicaid clients:

(A) For Medicare covered services and then only Medicaid payment of a client’s Medicare cost-sharing expenses for DMEPOS services when all of the following criteria are met:

(i) Client is a qualified Medicare beneficiary (QMB);

(ii) Service is covered by Medicare;

(iii) Medicare has paid on the specific code. Prior authorization is not required.

(B) Services not covered by Medicare:

(i) Only when the service or item is not available in the State of Oregon, and this is clearly substantiated by supporting documentation from the prescribing practitioner and maintained in the DMEPOS provider’s records;

(ii) Some examples of services not reimbursable to a non-contiguous out-of-state provider include but are not limited to incontinence supplies, grab bars;

(iii) Services billed must be covered under the OHP;

(iv) Services provided and billed to the Division shall be in accordance with all applicable Division rules.

(b) Medicaid-only clients:

(A) For a specific Oregon Medicaid client who is temporarily outside Oregon and only when the prescribing practitioner has documented that a delay in service may cause client harm;

(B) For foster care or subsidized adoption children placed out of state;

(C) Only when the service or item is not available in the State of Oregon, and this is clearly substantiated by supporting documentation from the prescribing practitioner and maintained in the DMEPOS provider’s records;

(D) Services billed must be covered under the OHP;

(E) Services provided and billed to the Division shall be in accordance with all applicable Division rules.

(20) A request may be made on any DMEPOS item, related supplies, or services that are not already identified as covered by the Division:

(a) The client’s physician must submit sufficient client-specific information and clinical documentation to the Division that demonstrates there is no equally effective, less costly covered item or service that meets the client’s medical needs;

(b) The client’s physician must certify that the less costly alternatives have been tried and failed or could be reasonably expected to fail or is inappropriate for the client;

(c) In no case may a requested service or item be approved unless it is medically appropriate as defined in OAR 410-120-0000 (Acronyms and Definitions) and 410-141-0000 and meets all requirements of this rule;

(d) Requests under this section shall be directed in accordance with OAR 410-122-0040 (Prior Authorization)(2).

(21) See General Rules OAR 410-120-1200 (Excluded Services and Limitations) Excluded Services and Limitations for more information on general scope of coverage and limitations.

Source: Rule 410-122-0080 — Conditions of Coverage, Limitations, and Restrictions, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-122-0080.

California:	Codes
Colorado:	C.R.S.
Nevada:	NRS
New York:	Laws
Oregon:	OAR, ORS
Texas:	Statutes
World:	Rome Statute, International Dictionary

OAR 410-122-0080 Conditions of Coverage, Limitations, and Restrictions

OAR 410-122-0080
Conditions of Coverage, Limitations, and Restrictions