Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers
Section 5160-10-19 - DMEPOS: positive airway pressure devices
Universal Citation: OH Admin Code 5160-10-19
Current through all regulations passed and filed through September 16, 2024
(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. 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.
7/2021). The
CMN
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
respiratory 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.
(3) Payment for a positive airway pressure device may
be made only if the following criteria are met:
(a)
In the absence of
positive airway pressure ,
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)
When positive airway pressure
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.
(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
respiratory study or during a one-week trial
period indicates that a variable or bilevel positive airway pressure device is
effective.
(C) Constraint. The provider of a positive airway pressure device cannot perform the qualifying respiratory study.
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