Ohio Admin. Code 5160-10-17 - DMEPOS: pneumatic compression devices and accessories
(A)
Payment may be made directly to a provider for a
pneumatic compression device or a related accessory only if the equipment and
supplies are used to treat either lymphedema in the extremities or chronic
venous insufficiency (CVI) with venous stasis ulcers. Accessories used for
pneumatic compression of the chest or trunk are not covered. Before prescribing
a pneumatic compression device, a practitioner must have found either that
there was no significant improvement or that significant symptoms persisted
when one of the following treatments was applied:
(1)
For lymphedema in
the extremities, four weeks of therapy involving the use of an appropriate
compression bandage system or compression garment (either prefabricated or
custom-fabricated), exercise, and elevation of the limb; or
(2)
For CVI, six
months of therapy involving the use of an appropriate compression bandage
system or compression garment, appropriate wound dressings, exercise, and
elevation of the limb.
(B)
Payment may be
made for the purchase of a pneumatic appliance. Payment may be made on a
rental/purchase basis for a pneumatic compressor.
(C)
The default form
is the ODM 02929, "Certificate of Medical Necessity: Pneumatic Compression
Devices and Accessories" (rev. 7/2018). The CMN must include the following
information:
(1)
A statement that previous treatment produced no
significant improvement or that significant symptoms persisted;
(2)
The date of the
most recent evaluation;
(3)
Identification by diagnosis code of the condition or
conditions necessitating a pneumatic compression device;
(4)
The expected
length of time (expressed as the number of months or as 'lifetime') during
which the individual will need the pneumatic compression
device;
(5)
A listing of symptoms observed, measurements taken, and
any other data that serve to establish the severity of the condition or
conditions;
(6)
Specification of the pneumatic compression device and
any accessories to be supplied;
(7)
Documentation of
the individual's clinical response to treatment during evaluation (including
changes in measurement results);
(8)
A brief summary
of the treatment plan, including the pressure to be used, the frequency and
duration of use, and a provisional monitoring schedule;
(9)
An assessment of
the individual's capacity for tolerating the prescribed treatment; and
(10)
A
statement about the ability of the individual (or someone authorized to assist
the individual) to use the device correctly and consistently.
(D)
The
initial rental of a pneumatic compression device starts a trial period of at
least thirty days and not more than ninety days. If the prescriber determines
during this trial period that the device satisfactorily meets the individual's
needs, then the provider may obtain a revised CMN during the trial period.
Unless the expected length of need is so short that additional rental would
cost less than purchase, the revised CMN will automatically be considered to
support purchase of the device.
Replaces: 5160-10-04
Notes
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 01/07/2010
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