Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers
Section 5160-10-08 - DMEPOS: high-frequency chest wall oscillation (HFCWO) devices
Universal Citation: OH Admin Code 5160-10-08
Current through all regulations passed and filed through September 16, 2024
(A) Coverage.
(1) Payment may be made for a high-frequency
chest wall oscillation (HFCWO) device on a rental/purchase basis.
(2)
Purchase of a
HFCWO device will not be considered without an initial trial period lasting at
least two months, excluding any portion that coincides with an inpatient
hospital stay. Payment may be made for rental during this trial period.
(3)
The default
certificate of medical necessity (CMN) is form ODM 10229, "Certificate of
Medical Necessity: High-Frequency Chest Wall Oscillation Devices"
(7/2018).
A CMN
includes the following elements:
(a) Evidence of a respiratory condition for
which a HFCWO device is an appropriate treatment, including but not limited to
the following examples:
(i) A diagnosis of
cystic fibrosis that has not been ameliorated by any other treatment;
(ii) A diagnosis of another respiratory
condition that produces chronic, excessive, retained bronchopulmonary
secretions; or
(iii) A medical
history of chronic or recurrent respiratory infections that
necessitate antibiotic treatment and multiple
hospitalizations and are unresolved by other bronchial hygiene
therapy;
(b) If
applicable, documentation that other airway-clearance treatments are
ineffective or contraindicated;
(c)
Specification of the duration and frequency of therapy; and
(d) If applicable, specification of other
individuals (e.g., siblings) with whom equipment is to be shared.
(4) If use of the HFCWO device is
to be continued in a residential setting after the initial trial period, the
CMN
is revised to include the following information:
(a) An attestation to the effectiveness of
the device during the trial period and every previous rental period;
(b) If applicable, specification of a change
in the duration or frequency of therapy; and
(c) A recommendation either for additional
rental or for purchase.
(B) Constraints and limitations.
(1) The need for a HFCWO device is not
established if the condition diagnosed is not accompanied by such symptoms of
respiratory distress as the accumulation of bronchopulmonary secretions or
bronchopulmonary infection. Common diagnoses that by themselves do not
establish need include but are not limited to the following examples:
(a) Amyotrophic lateral sclerosis;
(b) Asthma, uncomplicated;
(c) Bronchiectasis, uncomplicated;
(d) Cerebral palsy, any variety;
(e) Chronic obstructive pulmonary disease
(COPD);
(f) Chronic respiratory
failure, unspecified;
(g) Muscular
dystrophy;
(h) Pneumonia,
uncomplicated;
(i) Polyneuropathy;
and
(j) Quadriplegia.
(2) Payment for a HFCWO device
that has been dispensed on the basis of a diagnosis alone is subject to
recovery.
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