reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0325 - Power Wheelchair Base

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Indications and limitations of coverage and medical appropriateness:
(a) The Division may cover a power wheelchair
			 (PWC) when conditions of coverage in OAR 410-122-0080(1)  and all of the
			 following criteria are met:
(A) The client has
			 a mobility limitation that significantly impairs their ability to participate
			 in one or more mobility-related activities of daily living (MRADLs) in or out
			 of the home. MRADLs include but are not limited to tasks such as toileting,
			 feeding, dressing, grooming, and bathing. A mobility limitation is one that:
(i) Prevents the client from accomplishing an
			 MRADL entirely; or
(ii) Places the
			 client at reasonably determined heightened risk of morbidity or mortality
			 secondary to attempts to perform an MRADL; or
(iii) Prevents the client from completing an
			 MRADL within a reasonable time frame.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0330 - Power-Operated Vehicle

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications
			 and limitations of coverage and medical appropriateness:
(a) The Division may cover a power-operated
			 vehicle (POV) when conditions of coverage in OAR 410-122-0080(1)  and all of the
			 following criteria are met:
(A) The client has
			 a mobility limitation that significantly impairs their ability to participate
			 in one or more mobility-related activities of daily living (MRADLs) in or out
			 of the home. MRADLs include but are not limited to tasks such as toileting,
			 feeding, dressing, grooming, and bathing. A mobility limitation is one that:
(i) Prevents the client from accomplishing an
			 MRADL entirely; or
(ii) Places the
			 client at reasonably determined heightened risk of morbidity or mortality
			 secondary to attempts to perform an MRADL; or
(iii) Prevents the client from completing an
			 MRADL within a reasonable time frame.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0340 - Wheelchair Options/Accessories

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Indications and limitations of coverage and medical appropriateness:
(a) The Division may cover options and
			 accessories for covered wheelchairs when the following criteria are met:
(A) The client has a wheelchair that meets
			 Division coverage criteria; and
(B)
			 The client requires the options/accessories to participate in one or more
			 mobility-related activities of daily living (MRADLs) in the home, community or
			 any non-institutional setting in which normal life activities take place. See
			 OAR 410-122-0010, Definitions for definition of MRADLs.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0360 - Canes and Crutches

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications
			 and Coverage: When prescribed by a practitioner for a client with a condition
			 causing impaired ambulation and there is a potential for ambulation.
(2) A white cane for a visually impaired
			 client is considered to be a self-help item and is not covered by the
			 Division.
(3) Table
			 122-0360.
Tables referenced are available from the agency.
To view attachments referenced in rule text,
click here to view
				  rule
.
Statutory/Other Authority: ORS
				  413.042 &
				  414.065
Statutes/Other Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0365 - Standing and Positioning Aids

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Indications and coverage: Standing frame systems, prone standers, supine
			 standers or boards, and accessories are covered when:
(a) The client is unable to stand or ambulate
			 independently due to conditions such as, but not limited to, neuromuscular or
			 congenital disorders, including acquired skeletal abnormalities;
(b) The client is at high risk for lower
			 extremity contractures that cannot be appropriately managed by other treatment
			 modalities (i.e., stretching, active therapy, home programs, etc)
(c) The client has been sequentially
			 evaluated by a physical or occupational therapist to make certain the client
			 can tolerate a standing or upright position and obtain medical benefit;
			 and,
(d) The client is following a
			 home therapy program for the stander established by a physical or occupational
			 therapist; and
(e) The home is able
			 to accommodate the equipment; and
(f) The weight of the client does not exceed
			 manufacturer's weight capacity; and
(g) The client has demonstrated an ability to
			 utilize the standing aid independently or with assistance from a caregiver;
			 and
(h) The client has demonstrated
			 compliance with other programs; and
(i) The client has demonstrated a successful
			 trial period in a monitored setting; and
(j) The client does not have access to
			 equipment from another source.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0375 - Walkers

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications and
			 Limitations of Coverage:
(a) A standard
			 walker (E0130, E0135, E0141, E0143) and related accessories are covered if both
			 of the following criteria are met:
(A) When
			 prescribed by a treating practitioner for a client with a medical condition
			 impairing ambulation and there is a potential for increasing ambulation;
			 and
(B) When there is a need for
			 greater stability and security than provided by a cane or crutches;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0380 - Hospital Beds

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications and
			 limitations of coverage and medical appropriateness: The Division may cover
			 some hospital beds for a covered condition including:
(a) A fixed height hospital bed (E0250,
			 E0251, E0290, E0291, E0328) when the client meets at least one of the following
			 criteria:
(A) Has a medical condition that
			 requires positioning of the body in ways not feasible with an ordinary bed.
			 Elevation of the head/upper body less than 30 degrees does not usually require
			 the use of a hospital bed;
(B)
			 Requires positioning of the body in ways not feasible with an ordinary bed in
			 order to alleviate pain;
(C)
			 Requires the head of the bed to be elevated more than 30 degrees most of the
			 time due to congestive heart failure, chronic pulmonary disease, or problems
			 with aspiration. Pillows or wedges shall have been considered and ruled
			 out;
(D) Requires traction
			 equipment that can only be attached to a hospital bed;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0400 - Pressure Reducing Support Surfaces

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications and limitations of coverage
			 and medical appropriateness:
(a) Group 1
			 (A4640, E0181-E0182, E0184-E0189, and E0196-E0199):
(A) The Division may cover a Group 1 support
			 surface when the client meets:
(i) Criterion
			 (I), or;
(ii) Criteria (II) or
			 (III) and at least one of criteria (IV)-(VII):
(I) Completely immobile - i.e., client cannot
			 make changes in body position without assistance;
(II) Limited mobility - i.e., client cannot
			 independently make changes in body position significant enough to alleviate
			 pressure;
(III) Any stage pressure
			 ulcer on the trunk or pelvis;
(IV)
			 Impaired nutritional status;
(V)
			 Fecal or urinary incontinence;
(VI)
			 Altered sensory perception;
(VII)
			 Compromised circulatory status;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0420 - Hospital Bed Accessories

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Table
			 122-0420, Hospital Bed Accessories Procedure codes - Trapeze Bars:
(a) Indications and coverage: Trapeze bars
			 are indicated when a client needs this device to sit up because of respiratory
			 condition, to change body position for other medical reasons, or to get in or
			 out of bed;
(b) The Division of
			 Medical Assistance Programs (Division) may consider coverage for bariatric
			 trapeze bars only coded as E1399 (durable medical equipment, miscellaneous) for
			 a client residing in a nursing facility), subject to service limitations of
			 Division rules, only when the following requirements are met:
(A) The client meets the conditions of
			 coverage as specified in this rule; and
(B) The bariatric trapeze bar has been
			 assigned code E1399 by the Medicare Pricing, Data Analysis and Coding (PDAC)
			 contractor;
(C) Supporting
			 documentation has been submitted to the appropriate authorizing authority for
			 prior authorization;
(c)
			 Documentation of medical appropriateness which has been reviewed and signed by
			 the prescribing practitioner must be kept on file by the DME
			 provider;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0475 - Therapeutic Shoes for Diabetics

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Indications and Coverage:
(a) For each
			 client, coverage of the footwear and inserts is limited to one of the following
			 within one calendar year:
(A) One pair of
			 custom-molded shoes (including inserts provided with such shoes) and two
			 additional pair of inserts; or
(B)
			 One pair of extra-depth shoes (not including inserts provided with such shoes)
			 and three pairs of inserts.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0480

Current through Register Vol. 63, No. 7, July 1, 2024
Tables referenced are not included in rule text.
Click here for PDF copy of
				  table(s)
Stat. Auth.: ORS
				  413.042 &
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0500

Current through Register Vol. 63, No. 7, July 1, 2024
Tables referenced are not included in rule text.
Click here for PDF copy
				  of table(s)
.
Stat. Auth.: ORS
				  413.042 &
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0510 - Osteogenesis Stimulator

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Definitions:
(a) An electrical osteogenesis
			 stimulator is a device that provides electrical stimulation to augment bone
			 repair;
(b) A noninvasive
			 electrical stimulator is characterized by an external power source that is
			 attached to a coil or electrodes placed on the skin or on a cast or brace over
			 a fracture or fusion site;
(c) An
			 ultrasonic osteogenesis stimulator is a noninvasive device that emits low
			 intensity, pulsed ultrasound signals to stimulate fracture healing. The device
			 is applied to the surface of the skin at the fracture site and ultrasound waves
			 are emitted via conductive coupling gel to stimulate fracture
			 healing;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0525 - External Insulin Infusion Pump

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications and limitations of coverage
			 and medical appropriateness:
(a) The Division
			 may cover an external insulin infusion pump for the administration of
			 continuous subcutaneous insulin for the treatment of diabetes mellitus when
			 criterion (A) or (B) is met and criterion (C) or (D) is met:
(A) C-peptide testing requirement:
(i) The C-peptide level is less than or equal
			 to 110 percent of the lower limit of normal of the laboratory's measurement
			 method; or
(ii) For a client with
			 renal insufficiency and a creatinine clearance (actual or calculated from age,
			 weight, and serum creatinine) less than or equal to 50 ml/minute, a fasting
			 C-peptide level is less than or equal to 200 percent of the lower limit of
			 normal of the laboratory's measurement method; and
(iii) A fasting blood sugar obtained at the
			 same time as the C-peptide level is less than or equal to 225 mg/dl.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0540 - Ostomy Supplies

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications
			 and Limitations of Coverage and Medical Appropriateness: The Division may cover
			 ostomy supplies for a client with a surgically created opening (stoma) to
			 divert urine or fecal contents outside the body:
(a) Only one liquid barrier may be dispensed
			 at a time:
(A) A liquid or spray (A4369);
			 or
(B) Individual wipes or swabs
			 (A5120);
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0580 - Bath Supplies

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications
			 and limitations of coverage:
(a) The Division
			 may cover bath supplies when medically necessary and medically appropriate. A
			 rehab shower/commode chair may be covered when all of the following criteria
			 are met:
(A) Client is unable to use a
			 standard shower chair/bench due to a musculoskeletal condition;
(B) Client has positioning, trunk stability
			 or neck support needs that a standard shower chair/bench cannot
			 provide;
(C) The home (shower) can
			 accommodate a rehab/shower chair;
(D) Less costly alternatives have been
			 considered or tried and ruled out;
(E) The rehab shower/commode chair meets the
			 following specifications and standard features as a minimum:
(i) Constructed specifically for use as a
			 rehab shower/commode chair (corrosive resistant);
(ii) Swing-away or detachable arms;
(iii) Removable commode pan holder and
			 pan;
(iv) Adjustable removable
			 footrests;
(v) Wheel lock
			 system;
(F) The rehab
			 shower/commode chair must be supplied by a durable medical equipment,
			 prosthetics, orthotics and supplies (DMEPOS) provider that employs a
			 Rehabilitation Engineering and Assistive Technology Society of North America
			 (RESNA)-certified Assistive Technology Professional (ATP) who specializes in
			 wheelchairs and who has direct, in-person involvement in the rehab
			 shower/commode chair selection for the client;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0590 - Patient Lifts

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications and
			 coverage - A lift is covered if transfer between bed and a chair, wheelchair,
			 or commode requires the assistance of more than one person and, without the use
			 of a lift, the client would be bed confined.
(2) The areas within the client's residence
			 where the lift will be utilized must be able to accommodate and allow for the
			 effective use of the lift. The Division does not reimburse for adapting the
			 living quarters.
(3) A sling or
			 seat for a client lift may be covered as an accessory when ordered as a
			 replacement for the original equipment item.
(4) E0621 is included in the allowance for
			 E0630 when provided at the same time.
(5) E0635 may be covered only when a client
			 weighs 450 pounds or more;
(6)
			 Procedure codes:
(a) E0621 - Sling or seat,
			 client lift, canvas or nylon - Purchase - Prior authorization (PA)
			 required;
(b) E0630 - Client lift,
			 hydraulic with seat or sling (considered purchased after 10 months of rental) -
			 Purchase, rent or repair - PA required;
(c) E0635 - Client lift, electric, with seat
			 or sling - Rent only. This item is a capped rental and becomes the property of
			 the client after 10 months of continuous rental or when the usual purchase
			 price is reached, whichever is lesser. May be covered for a nursing facility
			 client - PA required.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0600 - Toilet Supplies

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division
			 may consider coverage for commodes when:
(a)
			 The client is physically incapable of utilizing regular toilet facilities. This
			 would occur when the client is confined to:
(A) A single room; or
(B) One level of the home environment and
			 there is no toilet on that level; or
(C) The home and there are no toilet
			 facilities in the home.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0620 - Miscellaneous Supplies

Current through Register Vol. 63, No. 7, July 1, 2024
Procedure Codes --
Table
				122-0620
.
Tables referenced are not included in rule text.
Click here for PDF copy
				  of table(s)
.
Stat. Auth.: ORS
				  413.042 &
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0625 - Surgical Dressing

Current through Register Vol. 63, No. 7, July 1, 2024
Procedure Codes:
Table 122-0625
Surgical
				Dressing.
Tables referenced are not included in rule text.
Click here for PDF copy
				  of table(s)
.
Stat. Auth.: ORS
				  413.042 &
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0630 - Incontinent Supplies

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division
			 may cover incontinent supplies for urinary or fecal incontinence as follows:
(a) Category I Incontinent Supplies: For up
			 to 200 units (any code or product combination in this category) per month,
			 unless documentation supports the medical appropriateness for a higher
			 quantity. For quantities over this limit a prior authorization shall be
			 required. When requesting multiple Category I product types (i.e., diapers and
			 liners) that exceed the allowable, prior authorization and documentation as
			 described in (4)(a)(D) of this rule are required;
(b) Category II Underpads:
(A) Disposable underpads: For up to 100 units
			 (any combination of T4541 and T4542) per month, unless documentation supports
			 the medical appropriateness for a higher quantity, up to a maximum of 150 units
			 per month;
(B) Reusable/washable
			 underpads: For up to eight units (any combination of T4537 and T4540) in a 12
			 month period;
(C) Category II
			 Underpads may be separately payable with Category I Incontinent Supplies with
			 documentation that supports medical appropriateness for the use of this
			 product;
(D) T4541 and T4542 are
			 not separately payable with T4537 and T4540 for the same dates of service or
			 anticipated coverage period. For example, if a provider bills and is paid for
			 eight reusable/washable underpads on a given date of service, a client would
			 not be eligible for disposable underpads for the subsequent 12
			 months;
(c) Category III
			 Washable Protective Underwear:
(A) For up to
			 12 units in a 12 month period;
(B)
			 Category III Washable Protective Underwear is not separately payable with
			 Category I Incontinent Supplies for the same dates of service or anticipated
			 coverage period. For example, if a provider bills and is paid for 12 units of
			 T4536 on a given date of service, a client would not be eligible for Category I
			 Incontinent Supplies for the subsequent 12 months;
(d) The following services require PA:
(A) A4335 (Incontinence supply;
			 miscellaneous);
(B) T4543
			 (Disposable incontinence product, brief/diaper, bariatric);
(C) T4544 (Disposable incontinence product,
			 protective underwear/pull-on);
(D)
			 Quantity of supplies greater than the amounts listed in this rule as the
			 maximum monthly utilization (e.g., more than 200 units per month of Category I
			 Incontinent Supplies, or 100 gloves per month).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0640 - Eye Prostheses

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Indications and coverage:
(a) An eye
			 prosthesis is indicated for a client (adult or child) with absence or shrinkage
			 of an eye due to birth defect, trauma, or surgical removal;
(b) For clients under age 21, the prescribing
			 practitioner shall determine and document medical appropriateness of the eye
			 prosthesis and related services;
(c) For clients age 21 and older, coverage is
			 limited as follows:
(A) Polishing and
			 resurfacing will be allowed on a twice per year basis;
(B) Replacement is covered every five years
			 if documentation supports medical appropriateness. An exception to this
			 limitation is allowed when clinical documentation supports medical
			 appropriateness for more frequent replacement;
(C) One enlargement (V2625) or reduction
			 (V2626) of the prosthesis is covered. Additional enlargements or reductions are
			 rarely medically indicated and are therefore covered only when clinical
			 documentation supports medical appropriateness.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0655 - External Breast Prostheses

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Indications and Limitations of Coverage and Medical Appropriateness:
(a) The Division of Medical Assistance
			 Programs (Division) may cover an external breast prosthesis for a client who
			 has had a mastectomy;
(b) An
			 external breast prosthesis garment, with mastectomy form (L8015) may be covered
			 for use in the postoperative period prior to a permanent breast prosthesis or
			 as an alternative to a mastectomy bra and breast prosthesis;
(c) An external breast prosthesis of a
			 different type may be covered if there is a change in the client's medical
			 condition necessitating a different type of item;
(d) The Division will pay for only one breast
			 prosthesis per side for the useful lifetime of the prosthesis;
(e) The Division will pay for a breast
			 prosthesis for a client residing in a nursing facility;
(f) Two prostheses, one per side, are allowed
			 for a client who has had bilateral mastectomies;
(g) More than one external breast prosthesis
			 per side is not covered;
(h) An
			 external breast prosthesis of the same type may be replaced if it is lost or is
			 irreparably damaged (this does not include ordinary wear and tear);
(i) Replacement sooner than the useful
			 lifetime because of ordinary wear and tear is not covered.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0658 - Gradient Compression Stockings/Sleeves

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications and Limitations of Coverage
			 and Medical Appropriateness:
(a) The Division
			 may cover gradient compression stockings/sleeves for the following indications:
(A) Ulceration due to chronic venous
			 insufficiency;
(B) Varicose veins
			 with ulcer or inflammation;
(C)
			 Phlebitis/thrombophlebitis;
(D)
			 Deep vein thrombosis (DVT) prophylaxis during pregnancy and postpartum or
			 immobilization due to surgery, trauma, or debilitation;
(E) Funded lymphedema conditions;
			 and
(F) Edema following a covered
			 surgery, fracture, burns, or other trauma;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0660 - Orthotics and Prosthetics

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Indications and limitations of coverage and medical appropriateness:
(a) The Division may cover some orthotics and
			 prosthetics for covered conditions;
(b) Use the current Healthcare Common
			 Procedure Coding System (HCPCS) Level II Guide for current codes and
			 descriptions;
(c) For adults,
			 follow Medicare current guidelines for determining coverage;
(d) For clients under age 21, the prescribing
			 practitioner shall determine and document medical appropriateness;
(e) The hospital is responsible for
			 reimbursing the provider for orthotics and prosthetics provided on an inpatient
			 basis;
(f) Evaluations, office
			 visits, fittings, and materials are included in the service provided;
(g) Evaluations will only be reimbursed as a
			 separate service when the provider travels to a client's residence to evaluate
			 the client's need;
(h) See Division
			 129, Speech-Language Pathology, Audiology and Hearing Aid Services for coverage
			 criteria for speech and audiology prosthetic devices and accessories.
(i) See OAR 410-122-0658  for coverage
			 criteria for mastectomy sleeves (L8010).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0662 - Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications and limitations of coverage
			 and medical appropriateness: The Division may cover some ankle-foot orthotics
			 (AFOs) and knee-ankle-foot Orthotics (KAFOs) and related services for a covered
			 condition, for this episode, when the covered device has not been billed to the
			 Division with a Current Procedure Terminology (CPT) code, Healthcare Common
			 Procedure Coding System (HCPCS) code or diagnosis code by any other healthcare
			 provider, and in addition specifically for:
(a) AFOs not used during ambulation: A static
			 AFO (L4396) may be covered when (A)-(E) are met:
(A) The client has a plantar flexion
			 contracture of the ankle (Internal Classification of Diseases (ICD)-10
			 diagnosis code M24.571, M24.572) with dorsiflexion on passive range of motion
			 testing of at least 10 degrees (i.e., a nonfixed contracture);
(B) There is a reasonable expectation of the
			 ability to correct the contracture;
(C) The contracture is interfering or
			 expected to interfere significantly with the client's functional
			 abilities;
(D) The static AFO is
			 used as a component of a therapy program that includes active stretching of the
			 involved muscles and/or tendons;
(E) The pre-treatment passive range of motion
			 is measured with a goniometer and an appropriate stretching program carried out
			 by professional staff (in a nursing facility) or caregiver (at home) is
			 documented in the client's treatment plan;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0678 - Dynamic Adjustable Extension/Flexion Device

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications and limitations of coverage
			 and medical appropriateness: The Division may cover some dynamic adjustable
			 extension/flexion devices for a covered condition when all of the following
			 conditions are met:
(a) As an adjunct to
			 physical therapy for clients with signs and symptoms of persistent joint
			 stiffness in the sub-acute injury or post-operative period (> 3 weeks but
			 < 4 months after injury or surgical procedure) when the device is applied
			 and managed under the direct supervision of a physical therapist;
(b) As an adjunct to physical therapy in the
			 acute post-operative period for clients who are undergoing additional surgery
			 to improve the range of motion of a previously affected joint when the device
			 is managed under the direct supervision of a physical therapist;
(c) For this episode, the device has not been
			 billed to the Division with a current procedure terminology (CPT) code,
			 healthcare common procedure coding system (HCPCS) code, or diagnosis code by
			 any other healthcare provider;
(d)
			 Reimbursement is limited to a maximum of four months per episode;
(e) Reimbursement is on a month-to-month
			 rental basis only.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0680 - Facial Prostheses

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Indications and Coverage:
(a) Covered when
			 there is loss or absence of facial tissue due to disease, trauma, surgery, or a
			 congenital defect;
(b) Adhesives,
			 adhesive remover and tape used in conjunction with a facial prosthesis are
			 covered. Other skin care products related to the prosthesis, including but not
			 limited to cosmetics, skin cream, cleansers, etc., are not covered;
(c) The following services and items are
			 included in the allowance for a facial prosthesis:
(A) Evaluation of the client;
(B) Pre-operative planning;
(C) Cost of materials;
(D) Labor involved in the fabrication and
			 fitting of the prosthesis;
(E)
			 Modifications to the prosthesis made at the time of delivery of the prosthesis
			 or within 90 days thereafter;
(F)
			 Repair due to normal wear or tear within 90 days of delivery;
(G) Follow-up visits within 90 days of
			 delivery of the prosthesis;
(d) Modifications to a prosthesis that occur
			 more than 90 days after delivery of the prosthesis and that are required
			 because of a change in the client's condition are covered;
(e) Repairs are covered when there has been
			 accidental damage or extensive wear to the prosthesis that can be repaired. If
			 the expense for repairs exceeds the estimated expense for a replacement
			 prosthesis, no payments can be made for the amount of the excess;
(f) Follow-up visits which occur more than 90
			 days after delivery and which do not involve modification or repair of the
			 prosthesis are non-covered services;
(g) Replacement of a facial prosthesis is
			 covered in cases of loss or irreparable damage or wear or when required because
			 of a change in the client's condition that cannot be accommodated by
			 modification of the existing prosthesis;
(h) When a prosthesis is needed for adjacent
			 facial regions, a single code must be used to bill for the item, whenever
			 possible. For example, if a defect involves the nose and orbit, this should be
			 billed using the hemi-facial prosthesis code and not separate codes for the
			 orbit and nose. This would apply even if the prosthesis is fabricated in two
			 separate parts.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0700 - Negative Pressure Wound Therapy Pumps

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications and limitations of coverage
			 and medical appropriateness - Initial Coverage: The Division may cover a
			 negative pressure wound therapy (NPWT) pump and supplies on a monthly basis for
			 up to four months on the most recent covered wound when either criterion (a) or
			 (b) is met:
(a) Ulcers and wounds in the home
			 setting or nursing facility:
(A) The client
			 has a chronic Stage III or IV pressure ulcer, neuropathic (for example,
			 diabetic) ulcer, venous or arterial insufficiency ulcer, or a chronic (being
			 present for at least 30 days) ulcer of mixed etiology;
(B) A complete wound therapy program
			 described by criterion (i) and criteria (ii), (iii), or (iv), as applicable
			 depending on the type of wound, must have been tried or considered and ruled
			 out prior to application of NPWT:
(i) For all
			 ulcers or wounds, the wound therapy program must include a minimum of all of
			 the following general measures, which have either been addressed, applied, or
			 considered and ruled out prior to application of NPWT:
(I) Documentation in the client's medical
			 record of evaluation, care, and wound measurements by a licensed medical
			 professional;
(II) Application of
			 dressings to maintain a moist wound environment;
(III) Debridement of necrotic tissue if
			 present;
(IV) Evaluation of and
			 provision for adequate nutritional status;
(ii) For Stage III or IV pressure ulcers:
(I) Appropriate turning and positioning of
			 the client;
(II) Use of a Group 2
			 or 3 support surface for pressure ulcers on the posterior trunk or pelvis (see
			 410-122-0400  Pressure Reducing Support Surfaces). If the ulcer is not on the
			 trunk or pelvis, a Group 2 or 3 support surface is not required; and
(III) Appropriate management of the client's
			 moisture and incontinence;
(iii) For neuropathic (for example, diabetic)
			 ulcers:
(I) The client has been on a
			 comprehensive diabetic management program, and;
(II) Reduction in pressure on a foot ulcer
			 has been accomplished with appropriate modalities;
(iv) For venous insufficiency ulcers:
(I) Compression bandages and/or garments have
			 been consistently applied, and;
(II) Leg elevation and ambulation have been
			 encouraged;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0710 - Special Needs Car Seats

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Special needs car seats are used to provide safe transportation to individuals
			 of all ages with health care needs such as orthopedic or medical needs that
			 cannot be met using conventional car seats for safe travel in a
			 vehicle.
(2) A special needs car
			 seat may be covered by the Division when a conventional car seat cannot be used
			 by a client because the client has a significant physical, neurological, or
			 orthopedic condition including one or more of the following (list not
			 all-inclusive):
(a) Inability to maintain an
			 unsupported sitting position independently;
(b) Significant head and trunk
			 instability;
(c) Significant
			 hypotonicity, hypertonicity, spasticity or muscle spasm which result in
			 uncontrollable movement and position changes;
(d) Orthopedic disease processes resulting in
			 significant bony fragility;
(e)
			 Significant contractures that would result in an inability to perform postural
			 corrections due to vehicle motion;
(f) Severe seizure activity that results in
			 uncontrollable movement and position change; or
(g) Orthopedic condition, such as a curvature
			 of the spine, which interferes with proper positioning;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 122 - DURABLE MEDICAL EQUIPMENT, PROSTHETIC ORTHOTICS AND SUPPLIES (DMEPOS) › Section 410-122-0730 - Continuous Glucose Monitoring Equipment and Supplies

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications and Limitations of Coverage
			 and Medical Appropriateness:
(a) The Division
			 shall cover personal, real-time continuous glucose monitoring (CGM) equipment
			 and supplies for clients with a diagnosis of type 1 diabetes mellitus, type 2
			 diabetes mellitus, or gestational diabetes when criteria in the Prioritized
			 List Guideline note 108 are met;
(b) Continuous glucose monitoring equipment
			 and supplies (E2102, E2103, A4238, A4239, A9276, A9277, A9278) require prior
			 authorization with clinical documentation to support that all criteria in OAR
			 Ch 410 Div. 122 DMEPOS rules, and Table 122-XXXX are met;
(c) Initial authorization shall be limited to
			 6 months from the date of Division's authorization. Continued use beyond the
			 initial 6 months authorization requires the provider send to the Division
			 current medical documentation of a client follow up visit with the treating
			 practitioner which supports that there continues to be a medical need, that the
			 requirements of this rule are met, and the client is regularly utilizing the
			 CGM and the data from the CGM to adjust insulin; regularly utilizing means that
			 the client used the device for at least 50% of the time since the date of the
			 initial authorization;
(d) CGM
			 equipment must be FDA approved for the age of the client;
(e) Insulin pumps with integrated CGM
			 function require prior authorization and must meet criteria in this rule and
			 OAR 410-122-0525;
(f) The Division
			 considers all other applications of real-time CGM to be investigational as the
			 effectiveness of its use has not been established in peer-reviewed professional
			 literature;
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-0010 - Foreword

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Oregon
			 Health Plan (OHP) offers Medicaid dental/denturist benefits on a
			 fee-for-service (FFS) basis and through Managed Care Entities (MCE). These
			 rules are Division rules to give FFS providers direction in the delivery of
			 dental services and in the preparation of dental care claims.
(2) MCE provide dental/denturist services
			 under an approved contract with the Authority. In accordance with
			 42 CFR
			 438.210, MCEs are required to provide medical
			 and dental services in an amount, duration and scope. In accordance with
			 42 CFR
			 438.210, MCEs are required to provide medical
			 and dental services in an amount, duration and scope that meets the minimum
			 requirements for amount, duration and scope for the same services provided
			 under FFS Medicaid., duration and scope for the same services provided under
			 FFS Medicaid.
(a) MCEs must adhere to the FFS
			 Dental/Denturist Services rules in providing the minimum standard of care
			 required per federal regulations and within the MCE's contract. MCEs may
			 provide services above and beyond these rules, according to each contract
			 agreement, State Plan, and 1115 Waiver.
(b) For members enrolled in an MCE, refer to
			 the MCE rules and contracts for services rendered above and beyond the minimum
			 standard found within the FFS Dental/Denturist Services rules or guides. The
			 MCE has the authority to provide more services than those found in these rules,
			 as long as the amount, duration and scope is no less than the amount, duration
			 and scope for the same services provided in these rules.
(c) The FFS Dental/Denturist rules do not
			 list every policy, procedure, and criteria for services. All Division rules
			 shall be used in conjunction with the General Rules for Oregon Medical
			 Assistance Programs (OAR chapter 410, division 120), and the Oregon Health Plan
			 (OHP) Administrative Rules for Managed Care Entities (OAR chapter 410, division
			 141).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1000 - Eligibility, Services Reviewed by the Division, Billing and the Dental Billing Invoice

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Eligibility:
(a) Providers must verify member eligibility
			 and benefit coverage of members on each day of service, and shall do so before
			 providing any service or billing to the:
(A)
			 Oregon Health Authority (referred to as "Authority" throughout these
			 rules);
(B) Health Systems Division
			 (referred to as "Division" throughout these rules);
(C) Oregon Health Plan (referred to as "OHP"
			 throughout these rules); or
(D)
			 Managed Care Entity (referred to as "MCE" throughout these rules).
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1025 - Program Integrity and Provider Audits

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Oregon Health Authority (Authority)
			 uses several approaches to promote program integrity and preventing Fraud,
			 waste and Abuse in the Medicaid program. OAR 410-120-1360  through 410-120-1580  generally describe Authority program integrity activities related to Medicaid
			 providers and payment. Providers enrolled with the Authority or under contract
			 with the Authority or the Department of Human Services (DHS) receiving payments
			 from the Authority or DHS are subject to audit or other post payment review
			 procedures for all payments applicable to items or services furnished or
			 supplied by the provider to or on behalf of Authority or DHS members.
(2) Providers shall comply with OAR
			 410-120-1510, OAR 461-195-0601  and the requirements therein for prompt
			 reporting of Fraud, waste and Abuse in the Medicaid program:
(a) Providers shall report all suspected
			 Fraud, waste and Abuse by a provider, including Fraud, waste or Abuse by its
			 employees or in the Authority administration, to the Medicaid Fraud Control
			 Unit (MFCU) of the Department of Justice (DOJ) or to the Authority's Office of
			 Program Integrity (OPI). Information on how to report may be found online at
			 all times:
https://www.oregon.gov/oha/FOD/PIAU/Pages/Report-Fraud.aspx
;
(b) Providers shall report all suspected
			 Fraud or Abuse by an Authority or DHS member to the DHS's Office of Payment and
			 Recovery (OPAR) Fraud Investigations Unit (FIU). Information on how to report
			 may be found online at all times:
http://www.oregon.gov/OHA/HSD/OHP//Pages/Policy-General-Rules.aspx
;
(c) Authority will take all actions necessary
			 to investigate and respond to credible allegations of Fraud, waste and Abuse in
			 the Medicaid program, including but not limited to suspending or terminating
			 the provider from participation in the medical assistance programs, withholding
			 payments or seeking recovery of payments made to the provider, or imposing
			 other sanctions provided under OAR 410-120-1400, state laws or regulations.
			 These actions and any outcome(s) will be reported to CMS, or other federal or
			 state of Oregon entities, or law enforcement, as appropriate.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1060 - Definition of Terms

Current through Register Vol. 63, No. 7, July 1, 2024
(1) "Abuse" has
			 the meaning as provided in OAR 410-120-0000.
(2) "Acute" has the meaning as provided in
			 OAR 410-120-0000.
(3) "Ambulatory
			 Surgical Center (ASC)" has the meaning as provided in OAR
			 410-120-0000.
(4) "Anesthesia"
			 refers to the Oregon Board of Dentistry administrative rules (OAR chapter 818,
			 division 026).
(5) "Anesthesia
			 Services" has the same meaning as OAR 410-120-0000  and means administration of
			 anesthetic agents to cause loss of sensation to the body or body
			 part.
(6) "By Report (BR)" has the
			 meaning as provided in OAR 410-120-0000.
(7) "Current Dental Terminology (CDT)" means
			 a listing of descriptive terms identifying dental procedure and nomenclature
			 used by the American Dental Association.
(8) "Citizenship Waived Medical" has the
			 meaning as provided in OAR 410-120-0000. The acronym "CWM" has the same
			 meaning.
(9) "CMS-416" means the
			 annual EPSDT participation report required by Section 1902(a)(43)(D) of the
			 Social Security Act, which assesses the Oregon Health Plan's effectiveness in
			 providing screening and dental services for EPSDT eligible children according
			 to the appropriate periodicity schedule. For the purpose of the measurement,
			 "Dental" services refer to services provided by or under the supervision of a
			 dentist. "Oral health" services refer to services provided by a licensed
			 practitioner that is not a dentist. For example, a pediatrician that applies a
			 fluoride varnish, or an independently practicing dental hygienist not under the
			 supervision of a dentist.
(10)
			 "Covered Services" has the meaning as provided in OAR 410-120-0000.
(11) "COVID-19 Emergency" means the period:
(a) Starting on the earliest of any COVID-19
			 public health emergency affecting the delivery of health care services and
			 declared by the Secretary of HHS pursuant to
			 42 U.S.C. §
										247d, by the Governor of Oregon, or by the
			 Authority; and
(b) Ending on the
			 latest of any COVID-19 public health emergency affecting the delivery of health
			 care services and declared by the Secretary of HHS pursuant to
			 42 U.S.C. §
										247d, by the Governor of Oregon, or by the
			 Authority.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 123 - DENTAL/DENTURIST SERVICES › Section 410-123-1100

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  413.042 &
				  414.065
Stats. Implemented: ORS
				  414.065