23 Miss. Code. R. 209-1.14 - Bi-level Positive Airway Pressure Device (BIPAP) With or Without an In-Line Heated Humidifier

A. Medicaid defines a bi-level positive airway pressure (BiPAP) device as a non-continuous, bi-level airway management device that cycles between the inspiratory and expiratory pressure levels in response to the patient's respiratory effort. The rise in pressure, during inspiration, supports the patient's breathing by splinting the airway to overcome the additional collapsing forces from inspiratory efforts. When inspiration has ended, the pressure drops at the point of exhalation removing the sensation of expiratory effort while still maintaining a therapeutic level of pressure in the circuit necessary to overcome collapsing forces in the airway.

B. Medicaid covers a BiPAP for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, for rental for an initial three (3) months trial period if one (1) or more of the following is met:

1. The beneficiary was unable to tolerate the necessary CPAP pressures,

2. The beneficiary has frequent central apneas that do not resolve with administration of CPAP, or

3. The beneficiary's baseline hypoxemia in cases involving chronic lung disease or hypoventilation syndromes is not corrected with administration of CPAP.

C. All related supplies are considered an integral part of the rental or purchase allowance of the BiPAP unit and separate charges for supplies or respiratory services are not covered.

D. Medicaid covers appropriate supplies for BiPAP units if owned by the beneficiary at maximum amounts expected to be medically necessary. Medicaid covers for amounts exceeding the maximum amount if there is documented justification and on individual bases.

E. After an initial three (3) month trial period, the BiPAP may be recertified up to seven (7) additional months with a BiPAP Compliance Medicaid Certificate of Medical Necessity completed by the ordering physician.

1. If the equipment was not effective or if the beneficiary was non-compliant, the equipment may be returned to the vendor.

2. The rental fees paid for the three (3) month trial period must apply toward the maximum reimbursement for purchase.

Notes

23 Miss. Code. R. 209-1.14

42U.S.C. § 1395m; Miss. Code Ann. §§ 43-13-117(17), 43-13-121.

Amended 9/1/2018