Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers
Section 5160-10-09 - DMEPOS: apnea monitors
Universal Citation: OH Admin Code 5160-10-09
Current through all regulations passed and filed through September 16, 2024
(A) Coverage.
(1)
Initial payment
may be made for rental of an apnea monitor for a period not to exceed four
months, and after the first four months payment may be made either for
additional rental or for purchase, only if the following conditions are
satisfied:
(a)
The monitoring unit meets current United States food and
drug administration guidelines.
(b)
The provider is
capable of performing all of the following services:
(i)
Arranging to have
certified individuals provide infant cardiopulmonary resuscitation (CPR)
training to caregivers;
(ii)
Providing education and instruction on the mechanical
aspects of monitors; and
(iii)
Providing a
technician twenty-four hours a day to service monitoring
equipment;
(c)
For this initial rental period, the following
information is recorded:
(i)
At least one clinical indication from the following
list:
(a)
The
occurrence of at least one apparent life-threatening event (ALTE) requiring
mouth-to-mouth resuscitation or vigorous stimulation;
(b)
A need for active
medical management of apnea of prematurity;
(c)
The occurrence of
sudden infant death syndrome (SIDS) in a sibling;
(d)
A need for home
oxygen therapy or ventilatory support (either invasive or non-invasive) and
associated technology-dependence;
(e)
Tracheotomy and
associated technology-dependence;
(f)
An abnormal
pneumogram at discharge from a medical facility;
(g)
Severe
gastroesophageal reflux and associated apnea;
(h)
Severe upper
airway abnormality (e.g., achondroplasia, Pierre Robin syndrome);
or
(i)
Another, specified disorder necessitating close
cardiorespiratory monitoring to facilitate a more timely discharge to home from
a medical facility; and
(ii)
An attestation
that appropriate caregivers are capable of being trained to use the monitor
properly; and
(d)
For additional rental or purchase, the following
information is recorded:
(i)
An attestation by the prescriber to the need for
continued home monitoring and supplies, including the following information
pertinent to the child's circumstances:
(a)
For a child who
is technology-dependent, documentation that the equipment or service on which
the child depends is still necessary and is still being used (evidenced, for
example, by a copy of a recent clinician follow-up report or home health agency
visit report noting equipment and services);
(b)
For a child who
is not technology-dependent, documentation of recent, clinically significant
apnea or bradycardia (evidenced, for example, by a copy of recent monitor data
or a recent pneumogram showing instances of apnea or bradycardia) or
documentation of a recent emergency department visit or hospital admission for
an ALTE; and
(c)
For a child whose sibling died of SIDS, the birth and
death dates of the sibling (for the purpose of indicating whether the child is
currently younger than the sibling was at the time of death);
and
(ii)
Either a full report of the information recorded by the
apnea monitor during the initial rental period or a summary of the information
accompanied by a statement that a full report is available on
request.
(2)
Payment for an
apnea monitor includes professional time, data recording, transmission or
printing, maintenance, and supplies.
(3)
The default
certificate of medical necessity (CMN) form is the ODM 02900, "Certificate of
Medical Necessity: Apnea Monitors" (rev. 7/2018).
(B) Constraints and limitations.
(1)
The following diagnoses, conditions, or circumstances are
not by themselves indications for monitoring:
(a)
Seizures or
seizure disorders in the absence of ALTEs;
(b)
Uncomplicated
hydrocephalus;
(c)
Developmental disability;
(d)
Terminal
illness;
(e)
Congenital heart defect, with or without associated
arrhythmia;
(f)
History of apnea in immediate siblings;
(g)
History of
monitor use with immediate siblings;
(h)
History of apnea
or SIDS in family members other than immediate siblings;
(i)
Parental anxiety
or family request for a monitor; and
(j)
Need to monitor
blood oxygen saturation.
(2)
Apnea monitoring
in the home does not include pneumograms. A medically necessary pneumogram is
ordered by a qualified prescriber and is based on the presence of appropriate
symptoms or conditions. No payment will be made for a pneumogram that is used
as a screening test in the absence of appropriate symptoms or conditions.
Replaces: 5160-10-09
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