OAR 410-122-0300
Light Therapy
(1)
Phototherapy (bilirubin light therapy):(a)
The Division may cover home phototherapy for a term or near-term infant whose elevated bilirubin is not due to a primary hepatic disorder or other hemolytic disorder that requires inpatient care;(b)
E0202 includes equipment rental, supplies, delivery, set-up, pick-up, training, instruction, and 24-hour on-call service necessary for the effective use of the equipment;(c)
Documentation by the treating physician shall indicate home phototherapy is the appropriate treatment modality;(d)
Home phototherapy may be covered for any of the following conditions:(A)
Jaundice in healthy term (>37 weeks) infant ready to be discharged or recently discharged from the hospital; feeding well/appears well with serum bilirubin values as follows:(i)
25–48 hours old ≥12 mg/dl total serum bilirubin; or(ii)
49–72 hours old ≥15 mg/dl total serum bilirubin; or(iii)
>72 hours old ≥ 17 mg/dl total serum bilirubin; or(B)
Jaundice in preterm infant <37 weeks when total serum bilirubin level is ≥10mg/dl;(e)
Treatment days will be determined based on lab values.(2)
Documentation Requirements:(a)
For services that require PA: Submit documentation for review that supports conditions of coverage as specified in this rule are met;(b)
For services that do not require PA: Medical records that support conditions of coverage as specified in this rule are met shall be on file with the DMEPOS provider and made available to the Division upon request.(3)
Table 122-0300 Light Therapy.
Source:
Rule 410-122-0300 — Light Therapy, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-122-0300.