(1)Indications and limitations of coverage:
(a)Mechanical ventilatory support may be provided to a client for the purpose of life support during therapeutic support of suboptimal cardiopulmonary function, or therapeutic support of chronic ventilatory failure;
(b)A ventilator may be covered by the Division for treatment of neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic obstructive pulmonary disease. This includes both positive and negative pressure types;
(c)A ventilator for pediatric home ventilator management may be covered on a case-by-case basis based on medical appropriateness, evidence-based medicine and best health practices.
(a)A primary ventilator may be covered if supporting documentation indicates:
(A)A client is unable to be weaned from the ventilator or is unable to be weaned from use at night; or
(B)Alternate means of ventilation were used without success; or
(C)A client is ready for discharge and has been on a ventilator more than 10 days;
(b)E0450, E0460, E0461 or E0472 may be covered if:
(A)A client has no respiratory drive either due to paralysis of the diaphragm or a central brain dysfunction; or
(B)A client has a stable, chronic condition with no orders to wean from the ventilator; or
(C)A client has had a trial with blood gases and has no signs or symptoms of shortness of breath or increased work of breathing; or
(D)A client has uncompromised lung disease;
(c)E0463 or E0464 may be covered if supporting documentation indicates:
(A)A client has chronic lung disease where volume ventilation may further damage lung tissue; or
(B)A client has a compromised airway or musculature and has respiratory drive and a desire to breathe; or
(C)A client will eventually be weaned from the ventilator; or
(D)A client has compromised respiratory muscles from muscular dystrophies or increased resistance from airway anomalies or scoliosis conditions.
(a)A secondary ventilator, identical or similar to the primary ventilator, may be covered when necessary to serve a different medical need of a client;
(b)For example (not all-inclusive), a secondary ventilator may be covered when:
(A)A client requires one type of ventilator (e.g., a negative pressure ventilator with a chest shell) for part of the day and needs a different type of ventilator (e.g., positive pressure respiratory assist device with a nasal mask) during the rest of the day; or
(B)A client is confined to a wheelchair who requires a ventilator permanently mounted on the wheelchair for use during the day and needs another ventilator of the same type for use while in bed.
(a)Reimbursement rates for ventilators are calculated based on consideration that break down or malfunction of a ventilator could result in immediate life-threatening consequences for a client. Therefore ventilators are reimbursed on a monthly rental payment for as long as the equipment is medically appropriate;
(A)The durable medical equipment (DME) provider ensuring that an appropriate and acceptable contingency plan to address emergency situations or mechanical failures of the primary ventilator is in place. This could mean that the provider furnishes a backup ventilator;
(B)Any equipment, supplies, services, including respiratory therapy (respiratory care) services, routine maintenance and training necessary for the effective use of the ventilator;
(c)Secondary Ventilators: The maximum reimbursement rate is one-half the maximum allowable fee for the primary ventilator.
(5)The client must have a telephone or reasonable access to one.
(6)A backup ventilator provided as a precautionary measure for emergency situations in which the primary ventilator malfunctions is not separately payable by the Division.
(7)Prior authorization (PA):
(a)PA is not required when E0450, E0460, E0461, E0463, E0464 or E0472 is dispensed as the primary ventilator. The provider is responsible to ensure all rule requirements are met;
(b)PA is required for a secondary ventilator:
(A)Payment authorization is required prior to the second date of service and before submitting claims. See Oregon Administrative Rule (OAR) 410-120-0000 (Acronyms and Definitions) (General Rules);
(B)Payment authorization will be given once all required documentation has been received and any other applicable rules and criteria have been met; and
(C)Payment authorization is obtained from the same authorizing authority as specified in OAR 410-122-0040 (Prior Authorization).
(a)For services requiring payment authorization or PA, submit documentation that supports coverage criteria in this rule are met;
(b)Documentation that coverage criteria have been met must be present in the client’s medical records, kept on file with the DME provider and made available to the Division on request. Table 122-0210
Rule 410-122-0210 — Ventilators,