Chapter 14 Durable Medical Equipment (DME)

Durable Medical Equipment (DME)Supplies for the Pulse Oximeter will only be paid for by Medicaid aftercompletion of the ten month rental period.Non disposable probes may be used for children whose weight is greaterthan 20 kilograms (2.2 kilograms = 1 pound) or greater than 44 pounds.Children 10 to 11 years old can use non disposable probes.A4606 - non disposable probe is limited to one per year per recipient.A4606 – disposable probe is limited to two per month per recipient.Volume Ventilator – Stationary or Portable (E0450-R) with backup ratefeature used with invasive interface.Volume Ventilator – Stationary or Portable (E0461-R) with backup ratefeature used with non- invasive interface.A ventilator is covered for EPSDT referred recipients. A physician must prescribe it asmedically necessary. Request for coverage of ventilators must be received by EDSwithin thirty calendar days after the equipment is dispensed. When the request is notreceived within the thirty day time frame for ventilators the thirty days will becalculated from the date the prior authorization request is received by EDS. All priorauthorization requests received with a date greater than thirty days from dispenseddate will be assigned an effective date based on actual date received by EDS if therecipient continues to meet medical criteria. No payment will be made for the daysbetween the dispensed date and the date assigned by the Prior Authorization Unit. Therecipient must meet the following conditions:• The recipient is unable to maintain respiration spontaneously.• The recipient is unable to maintain safe levels of arterial carbon dioxide or oxygenwith spontaneous breathing.• The recipient has a medical condition that requires mechanically assistedventilation that is appropriate for home use without continuous technical orprofessional supervision.The appropriate EPSDT Screening Referral form must be attached to the priorauthorization request. The information submitted must include documentation that therecipient meets the above criteria.Home Phototherapy (S9120)Home phototherapy is a covered service with prior authorization in the DME Programfor EPSDT referred recipients. To administer the treatment of phototherapy safely andproperly in the home, an attending physician must prescribe it as medically necessaryfor hyperbilirubinemia. EDS must receive requests for coverage within thirty calendardays after the first home phototherapy treatment.The attending physician is responsible for determining the length of time the infant is toreceive the therapy based on serum bilirubin levels and clinical condition of the infant.Treatment of bilirubin levels of 12.0 or less will not be covered.Providers of home phototherapy must meet the following:• Be enrolled as a Medicaid DME provider14-26 April 2005