Chapter 14 Durable Medical Equipment (DME)

Durable Medical Equipment (DME) 14iv. Effective January 1, 2005 for recertification for oxygen only followingqualifying sleep study which allows for approval of nocturnal oxygen, theDME supplier may perform the oximetry analysis to determine continuedmedical necessity for recipients receiving nocturnal oxygen only. Aprinted download of the oximetry results must be submitted with a priorauthorization request. Handwritten results will not be accepted.Added: (iv)EffectiveJanuary 1,2005 forrecertification…will not beaccepted.NOTE:There are no restrictions related to oxygen flow rate and eligibility for oxygencoverage. The restriction is related only to the procedure codes covered.Include a copy of the EPSDT Screening and Referral form with oxygen requestsfor children under age 21. This form is used to allow additional medical necessityequipment and/or supplies to be covered beyond current limitations. Only oneportable system consisting of one tank and up to four refills per month will beapproved based on a review of submitted medical justification.Pulse Oximeter - (E0445) RHypoxia is defined as insufficient oxygenation of the blood. Pulse oximetry is a noninvasivemethod of determining blood oxygen saturation levels to assist withdetermining the amount of supplemental oxygen needed by the patient.Request for coverage of pulse oximeters must be received by EDS within thirty daysafter the equipment is dispensed. When the request is not received within the thirtydaytime frame for pulse oximeters, the thirty days will be calculated from the date theprior authorization request is received by EDS. All prior authorization requestsreceived with a date greater than thirty days from dispensed date will be assigned aneffective date based on actual date received by EDS if the recipient continues to meetmedical criteria. No payment will be made for the days between the dispensed dateand the date assigned by the Prior Authorization Unit.Pulse oximeters are a covered service for EPSDT eligible individuals who are alreadyapproved for supplemental home oxygen systems and whose blood saturation levelsfluctuate, thus requiring continuous or intermittent monitoring to adjust oxygen delivery.To receive prior authorization, submit a written request to include, but not limited to, allthe following requirements:• A completed Form 342 with required supportive documentation• Copy of EPSDT form/referral• Copy of prior approval form for home oxygen (Form 360)The use of home pulse oximetry, for pediatric patients, is considered medicallyappropriate if one of the following criteria is met in addition to the documentationrequirements in B:April 2005 14-23