Ohio Admin. Code 5160-10-19 - DMEPOS: positive airway pressure devices

(A) Definition. "Apnea-hypopnea index (AHI)" is the mean number of episodes of apnea or hypopnea per hour recorded over a period of at least two hours without the use of a positive airway pressure device, reported by polysomnogram. The AHI may not be extrapolated or projected. Extrapolation or projection of the AHI is not permitted.

(B) Coverage.

(1) The default certificate of medical necessity (CMN) form is the ODM 01903, "Certificate of Medical Necessity: Positive Airway Pressure Devices" (rev. 7/2018 7/2021). The CMN must include includes the following information:

(a) A diagnosis of obstructive sleep apnea or other condition for which positive airway pressure is an appropriate treatment;

(b) The results of a sleep respiratory study comprising components for diagnosis and titration, performed either separately as two studies or consecutively as a split study; and

(c) An estimated length of need.

(2) A respiratory study may be performed with a positive airway pressure device that records relevant data automatically.

(2) (3) Payment for a positive airway pressure device may be made only if the following criteria are met:

(a) The diagnosis component of the sleep study, performed during at least two hours of recorded sleep without a In the absence of positive airway pressure device, the respiratory study yields the following results:

(i) An AHI of at least fifteen; or

(ii) An AHI of at least five coupled with documented evidence of any of the following conditions:

(a) Excessive sleepiness during waking hours;

(b) Insomnia;

(c) Mood disorder;

(d) Impaired cognition;

(e) Hypertension;

(f) Ischemic heart disease; or

(g) A history of stroke.

(b) The titration component of the sleep study, performed with a When positive airway pressure device, is applied, the respiratory study yields the following results:

(i) A decrease in the number of airway obstructions per hour; and

(ii) At least one of the following indications of effectiveness:

(a) An absolute increase in oxygen saturation to at least eighty-nine per cent;

(b) A relative increase in oxygen saturation of at least fifteen per cent; or

(c) Other clinical improvement recognized by the department.

(4) A need for oxygen is established if a positive airway pressure device is effective during a respiratory study only when supplemental oxygen is administered simultaneously. That need for oxygen is presumed to last as long as the need for the positive airway pressure device, and no further respiratory study is necessary to confirm a continued need for oxygen.

(3) (5) Payment for a variable or bilevel positive airway pressure device (i.e., a positive airway pressure device that produces different inspiratory and expiratory pressure levels) may be made only if the following criteria are met:

(a) A positive airway pressure device that produces a single pressure level has been tried and found to be ineffective; and

(b) Evidence gathered during the titration component of the sleep respiratory study or during a one-week trial period indicates that a variable or bilevel positive airway pressure device is effective.

(4) A need for oxygen is established if a positive airway pressure device is effective during a sleep study only when supplemental oxygen is administered simultaneously. That need for oxygen is presumed to last as long as the need for the positive airway pressure device, and no further sleep study is required to confirm a continued need for oxygen.

(C) Constraint. The provider of a positive airway pressure device may not cannot perform the qualifying sleep respiratory study.

Notes

Ohio Admin. Code 5160-10-19

Effective: 7/1/2021
Five Year Review (FYR) Dates: 4/16/2021 and 07/01/2026
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02, 5165.47
Prior Effective Dates: 12/30/1991, 07/01/1993, 07/01/1994, 01/01/1995, 08/01/1998, 10/01/2004, 01/01/2008, 07/16/2018