OAR 410-122-0540
Ostomy Supplies

(1)

Indications and Limitations of Coverage and Medical Appropriateness: The Division of Medical Assistance Programs (Division) may cover ostomy supplies for a client with a surgically created opening (stoma) to divert urine or fecal contents outside the body:

(a)

Only one liquid barrier may be dispensed at a time:

(A)

A liquid or spray (A4369); or

(B)

Individual wipes or swabs (A5120);

(b)

For a client with a continent stoma, only one of the following means to prevent/manage drainage may be covered on a given day:

(A)

Stoma cap (A5055);

(B)

Stoma plug (A5081); or

(C)

Gauze pads (A6216);

(c)

For a client with a urinary ostomy, only one of the following may be covered for drainage at night:

(A)

Bag (A4357); or

(B)

Bottle (A5102);

(d)

Provision of ostomy supplies for a client is limited to a three month supply;

(e)

The following services are not covered:

(A)

Ostomy clamps;

(B)

Ostomy supplies when a client is in a covered home health episode;

(C)

Pouch covers.

(2)

Documentation Requirements:

(a)

For miscellaneous ostomy supplies (A4421) ,submit documentation which supports coverage criteria as specified in this rule are met to the responsible unit for prior authorization;

(b)

Medical records which support conditions of coverage as specified in this rule are met must be kept on file by the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider and made available to the Division on request;

(c)

A client’s medical records must support the justification for supplies billed to the Division including when a greater quantity of supplies than the amounts listed in this rule are dispensed (e.g., client has more than one ostomy).

(3)

Table 122-0540-1, Maximum Quantity of Supplies — Monthly Basis.

(4)

Table 122-0540-2, Maximum Quantity of Supplies — 6-Month Basis.

(5)

Table 122-0540-3, Faceplate Systems.

(6)

Table 122-0540-4, Procedure Codes.
[ED. NOTE: Tables referenced rule are available from the agency.]
[ED. NOTE: To view attachments referenced in rule text, click here to view rule.]

Source: Rule 410-122-0540 — Ostomy Supplies, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-122-0540.

410‑122‑0010
Definitions 410‑122‑0020
Orders 410‑122‑0040
Prior Authorization 410‑122‑0080
Conditions of Coverage, Limitations, and Restrictions 410‑122‑0090
Face-to-Face Encounter Requirements (for Fee-For-Service Clients) 410‑122‑0180
Healthcare Common Procedure Coding System Level II Coding 410‑122‑0182
Legend 410‑122‑0184
Repairs, Servicing, Replacement, Delivery, and Dispensing 410‑122‑0186
Payment Methodology 410‑122‑0188
DMEPOS Rebate Agreements 410‑122‑0200
Pulse Oximeter for Home Use 410‑122‑0202
Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea 410‑122‑0203
Oxygen and Oxygen Equipment 410‑122‑0204
Nebulizer 410‑122‑0205
Respiratory Assist Devices 410‑122‑0206
Intermittent Positive Pressure Breathing 410‑122‑0207
Respiratory Supplies 410‑122‑0208
Suction Pumps 410‑122‑0209
Tracheostomy Care Supplies 410‑122‑0210
Ventilators 410‑122‑0211
Cough Stimulating Device 410‑122‑0220
Pacemaker Monitor 410‑122‑0240
Apnea Monitors for Infants 410‑122‑0250
Breast Pumps 410‑122‑0260
Home Uterine Monitoring 410‑122‑0280
Heating/Cooling Accessories 410‑122‑0300
Light Therapy 410‑122‑0320
Manual Wheelchair Base 410‑122‑0325
Power Wheelchair Base 410‑122‑0330
Power-Operated Vehicle 410‑122‑0340
Wheelchair Options/Accessories 410‑122‑0360
Canes and Crutches 410‑122‑0365
Standing and Positioning Aids 410‑122‑0375
Walkers 410‑122‑0380
Hospital Beds 410‑122‑0400
Pressure Reducing Support Surfaces 410‑122‑0420
Hospital Bed Accessories 410‑122‑0475
Therapeutic Shoes for Diabetics 410‑122‑0510
Osteogenesis Stimulator 410‑122‑0515
Neuromuscular Electrical Stimulator (NMES) 410‑122‑0520
Glucose Monitors and Diabetic Supplies 410‑122‑0525
External Insulin Infusion Pump 410‑122‑0540
Ostomy Supplies 410‑122‑0560
Urological Supplies 410‑122‑0580
Bath Supplies 410‑122‑0590
Patient Lifts 410‑122‑0600
Toilet Supplies 410‑122‑0620
Miscellaneous Supplies 410‑122‑0625
Surgical Dressing 410‑122‑0630
Incontinent Supplies 410‑122‑0640
Eye Prostheses 410‑122‑0655
External Breast Prostheses 410‑122‑0658
Gradient Compression Stockings/Sleeves 410‑122‑0660
Orthotics and Prosthetics 410‑122‑0662
Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses 410‑122‑0678
Dynamic Adjustable Extension/Flexion Device 410‑122‑0680
Facial Prostheses 410‑122‑0700
Negative Pressure Wound Therapy Pumps 410‑122‑0720
Pediatric Wheelchairs
Last Updated

Jun. 8, 2021

Rule 410-122-0540’s source at or​.us