Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-10 - Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers › Section 5160-10-06 - DMEPOS: wearable cardioverter-defibrillators

Current through all regulations passed and filed through July 1, 2024
(A)
								Prescribing
			 provider. Only a physician experienced in the management of patients at risk
			 for sudden cardiac death (SCD), such as a cardiologist, electrophysiologist, or
			 cardiac surgeon, may prescribe a wearable cardioverter-defibrillator
			 (WCD).
(B)
								Coverage.
(1)
									Separate payment may be made for a WCD furnished to a
			 resident of a long-term care facility (LTCF).
(2)
									Payment may be
			 made for a WCD on a rental basis only.
(3)
									The default
			 certificate of medical necessity (CMN) is form ODM 10275, "Certificate of
			 Medical Necessity: Wearable Cardioverter-Defibrillators"
			 (9/2021).
(4)
									A completed CMN confirms that the following criteria
			 are met:
(a)
										The individual is at high risk of SCD, established by the
			 occurrence or presence of medically indicated factors including but not limited
			 to the following examples:
(i)
											A documented episode of ventricular fibrillation or
			 sustained ventricular tachyarrhythmia lasting at least thirty seconds, either
			 spontaneous or induced during an electrophysiologic (EP) study but not
			 attributable to a transient or reversible cause and not occurring within the
			 first forty-eight hours after an acute myocardial infarction;
(ii)
											Familial or
			 hereditary conditions with a high risk of life-threatening ventricular
			 tachyarrhythmia, such as long QT syndrome or hypertrophic cardiomyopathy;
			 or
(iii)
											Recent myocardial infarction, dilated cardiomyopathy,
			 newly diagnosed non-ischemic cardiomyopathy, coronary artery bypass graft
			 (CABG), or percutaneous coronary intervention (PCI), with a left ventricular
			 ejection fraction (measured during either the acute or post-acute phase) of not
			 greater than thirty-five per cent; and
(b)
										Treatment of the
			 individual with an implantable cardioverter-defibrillator (ICD) is precluded by
			 any of the following considerations:
(i)
											A currently implanted ICD needs to be
			 explanted;
(ii)
											An infection prevents initial implantation of an ICD;
			 or
(iii)
											Some condition or circumstance, either temporary or
			 permanent, contraindicates ICD implantation surgery.
(c)
										The individual is
			 able to wear a properly fitted WCD at least ninety per cent of the time (an
			 average total of at least twenty-one and a half hours per day).
(5)
									A WCD
			 is generally covered for a period of ninety days at a time. Additional
			 ninety-day coverage periods may be authorized if the provider submits
			 documentation, such as a detailed statement signed by the treating physician
			 that the WCD continues to be medically necessity and the individual continues
			 to use it correctly. Authorization may be given for indefinite (lifetime)
			 coverage if the provider submits appropriate documentation, such as a detailed
			 statement signed by the treating physician and a description of the
			 circumstances that preclude future implantation of an ICD.
(6)
									Rental payment
			 includes necessary replacement of batteries, electrodes, and the cover
			 garment.