OAR 410-122-0205
Respiratory Assist Devices
(1)
As referenced in this policy, non-invasive positive pressure respiratory assistance (NPPRA) is the administration of positive air pressure, using a nasal and/or oral mask interface which creates a seal, avoiding the use of more invasive airway access (e.g., tracheostomy).(2)
Indications and Coverage — General:(a)
The “treating prescribing practitioner” must be one who is qualified by virtue of experience and training in non-invasive respiratory assistance, to order and monitor the use of respiratory assist devices (RAD);(b)
For the purpose of this policy, polysomnographic studies must be performed in a sleep study laboratory, and not in the home or in a mobile facility. The sleep study laboratory must comply with all applicable state regulatory requirements;(c)
For the purpose of this policy, arterial blood gas, sleep oximetry and polysomnographic studies may not be performed by a durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) provider. For purposes of this policy’s coverage and payment guidelines, a DMEPOS provider is not considered a qualified provider or supplier of these tests;(d)
If there is discontinuation of usage of E0470 or E0471 device at any time, the provider is expected to ascertain this, and stop billing for the equipment and related accessories and supplies.(3)
Coverage criteria for E0470 and E0471 devices – Table 122-0205-1.(4)
Documentation:(a)
The following documentation must be submitted with the request for prior authorization (PA) and the original kept on file by the provider:(A)
An order for all equipment and accessories including the client’s diagnosis, an ICD-10-CM code signed and dated by the treating prescribing practitioner;(B)
Summary of events from the polysomnogram, if required in this rule under the indications and coverage section or Table 122-0205-1;(C)
Arterial blood gas results, if required under the indications and coverage section or Table 122-0205-1;(D)
Sleep oximetry results, if required under the indications and coverage section or Table 122-0205-1;(E)
Treating prescribing practitioner statement regarding medical symptoms characteristic of sleep-associated hypoventilation, including, but not limited to daytime hypersomnolence, excessive fatigue, morning headache, cognitive dysfunction, and dyspnea;(F)
Other treatments that have been tried and failed. To be submitted in addition to the above at the fourth month review;(b)
A copy of the Evaluation of Respiratory Assist Device (Division 2461) completed and signed by the client, family member or caregiver;(c)
Clients currently using BiPapS and BiPap ST are not subject to the new criteria.(5)
Table 122-0205-1, Respiratory Assist Devices.(6)
Table 122-0205-2, Procedure Codes.
Source:
Rule 410-122-0205 — Respiratory Assist Devices, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-122-0205.