reglab/statecodes huggingface dataset:
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0280 - Billing Quantities, Metric Quantities and Package Sizes

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Use the actual
			 metric quantity dispensed when billing (up to four decimal places).
(2) Use the following units when billing
			 products:
(a) Solid substances (e.g.,
			 powders, creams, ointments, etc.), bill per Gram;
(b) Solid substances that are reconstituted
			 with a liquid (e.g., dry powder ampules and vials) such as antibiotic vials or
			 piggybacks must be billed in metric quantity of one each;
(c) Tablets, capsules, suppositories,
			 lozenges, packets; bill per each unit. Oral contraceptives are to be billed per
			 each tablet;
(d) Injectables that
			 are prepackaged syringe -- (e.g., tubex, carpujects), bill per ml.;
(e) Prepackaged medications and unit doses
			 must be billed per unit (tablet or capsule). Unit dose liquids are to be billed
			 by ml.;
(f) Fractional units: Bill
			 exact metric decimal quantities dispensed.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0300 - CMS Federal Upper Limits for Drug Payments

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Centers for Medicare and Medicaid
			 Services (CMS) Federal Upper Limits for Drug Payments listing of multiple
			 source drugs meets the criteria set forth in
			  42 CFR
			 447.332 and 1927(e)  of the Act as amended by
			 OBRA 1993 and the DRA 2005.
(2)
			 Payments for multiple source drugs must not exceed, in the aggregate, payment
			 levels determined by applying to each drug entity a reasonable dispensing fee
			 (established by the State and specified in the State Plan), plus an amount
			 based on the limit per unit. CMS has determined the amount based on the limit
			 per unit to be equal to 250 percent of the Average Manufacturer's Price (AMP).
			 CMS will post the AMP to a Website available to the public on a quarterly
			 basis.
(3) The FUL drug listing is
			 published in the State Medicaid Manual, Part 6, Payment for Services, Addendum
			 A. The most current Transmittals and subsequent changes are posted to the CMS
			 website
			 https://www.medicaid.gov/medicaid/prescription-drugs/pharmacy-pricing/index.html
			 [File Link Not Available].
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 121 - PHARMACEUTICAL SERVICES › Section 410-121-0420 - DESI Less-Than-Effective Drug List

Current through Register Vol. 63, No. 7, July 1, 2024
(1) An October 23, 1981 ruling by District of
			 Columbia Federal Court directed the Department of Health and Human Services to
			 stop reimbursement, effective October 30, 1981, under Medicaid and Medicare
			 Part B for all DESI less-than-effective drugs which have reached the Federal
			 Drug Administration Notice-of-Opportunity-for-Hearing stage.
(2) In accordance with Section 1903(i)(5) of
			 the Social Security Act, federal funds participation (FFP) is not available for
			 drugs deemed Less Than Effective (LTE) or Identical, Related of Similar (IRS)
			 drugs for which the Food and Drug Administration (FDA) issued a Notice of
			 Opportunity for a Hearing (NOOH) for all labeled indications. These drugs are
			 also termed Drug Efficacy Study Implementation (DESI) drugs. Division does not
			 reimburse for drugs designated as less than effective or drugs identical,
			 related, or similar to a DESI drug.
(3) A current list of DESI LTE/IRS drugs is
			 available at
https://www.medicaid.gov/medicaid/prescription-drugs/medicaid-drug-rebate-program/medicaid-drug-rebate-program-data/index.html
.
			 DESI drugs are identified by Covered outpatient Drug (COD) Status of 5 or
			 6.
(4) The US Food & Drug
			 Administration (FDA) has the responsibility of determining the DESI status of a
			 drug product.
Statutory/Other Authority: ORS
				  413.042 & 414.325
Statutes/Other Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0580 - Oregon Medicaid and Pharmaceutical Manufacturers' Dispute Resolution Procedures

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Within
			 60 days after the end of each calendar quarter, the Division of Medical
			 Assistance Programs (DMAP) shall report the number of units dispensed for each
			 drug National Drug Code (NDC) for which payment was made to the manufacturer of
			 said product. Utilization reports to manufacturers shall follow this schedule:
(a) The period from January 1 through March
			 31 will be Quarter 1. Quarter 1 invoices shall be due by May 30 of that same
			 year;
(b) The period from April 1
			 through June 30 will be Quarter 2. Quarter 2 invoices shall be due by August 29
			 of that same year;
(c) The period
			 from July 1 through September 30 will be Quarter 3. Quarter 3 invoices shall be
			 due by November 29 of that same year;
(d) The period from October 1 through
			 December 31 will be Quarter 4. Quarter 4 invoices shall be due by February 29
			 of the following year.
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-0625 - Items Covered in the All-Inclusive Rate for Nursing Facilities

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 all-inclusive rate for nursing facilities includes but is not limited to
			 various drug products and OTC items. DMAP requires that nursing facilities be
			 billed for these items.
(2) The
			 all-inclusive list is available for downloading in the Division of Medical
			 Assistance Programs Web page on the Oregon Health Authority's
			 website.
Stat. Auth.: ORS
				  409.025,
				  409.040,
				  409.110,
				  413.042 &
				  414.065
Stats. Implemented: ORS
				  414.065
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-2000 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  414.320
Stats. Implemented: ORS
				  414.312 -
				  414.320
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-2005 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  414.320
Stats. Implemented: ORS
				  414.312 -
				  414.320
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-2010 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  414.320
Stats. Implemented: ORS
				  414.312 -
				  414.320
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-2020 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  414.320
Stats. Implemented: ORS
				  414.312 -
				  414.320
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-2030 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  414.320
Stats. Implemented: ORS
				  414.312 -
				  414.320
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-2050 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  414.320
Stats. Implemented: ORS
				  414.312 -
				  414.320
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-2065 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  414.312
Stats. Implemented: ORS
				  414.312,
				  414.314,
				  414.316 &
				  414.318
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-3000 - Runumbered

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Purpose. The
			 AIDS Drug Assistance Program (ADAP) provides medications for the treatment of
			 HIV disease. The program is primarily funded through Part B of the Ryan White
			 Treatment Modernization Act, which provides grants to states and territories.
			 The Oregon Health Authority shall administer the federal funds awarded under
			 Part B of the Ryan White Treatment Modernization Act for the State of
			 Oregon.
(2) Services. Program funds
			 may be used to provide access to medication, purchase health insurance for
			 eligible clients and services that enhance access, adherence, and monitoring of
			 drug treatments.
(3) Eligibility:
			 Individuals must provide documentation of a HIV diagnosis and meet income and
			 resource guidelines as set by the Oregon Health Authority and other criteria as
			 defined in the Ryan White Treatment Modernization Act.
(4) This program shall be in effect as long
			 as authorized funds are available.
(5) Provider Payments: CAREAssist will make
			 payments to providers for medical services provided to CAREAssist and Bridge
			 clients to the extent funds are available. Payments made by CAREAssist on
			 behalf of its clients must be accepted by the provider as full payment for the
			 services provided.
(a) CAREAssist as the last
			 payer: Before a provider bills CAREAssist for medical services provided to
			 CAREAssist clients, all other insurance(s) for which the client is eligible
			 must be billed by the provider. Only the uncompensated balance, which is the
			 portion the clients must pay, is eligible for payment under this
			 rule.
(b) CAREAssist as the primary
			 payer: If a CAREAssist client has no insurance or when these services are not
			 covered due to a pre-existing exclusion imposed by insurance, CAREAssist will
			 pay for out-patient service CPT codes. When CAREAssist acts as the primary
			 provider, CAREAssist will pay providers at 125 percent of the Oregon Division
			 of Medical Assistance Programs (Medicaid) reimbursement rate. A current fee
			 schedule for the Oregon Division of Medical Assistance Programs can be found at
			 http://www.oregon.gov/DHS/healthplan/data_pubs/feeschedule/downloads.shtml
			 [File Link Not Available].
(c) For
			 Bridge clients: For purposes of this rule, Bridge client refers to anyone
			 enrolled in the Bridge program which provides temporary financial assistance to
			 individuals for accessing HIV treatment while applying for long term medical
			 insurance. CAREAssist will reimburse providers at 125 percent of the Oregon
			 Division of Medical Assistance Programs (Medicaid) rate for a limited number of
			 service CPT codes. A list of covered service codes available to Bridge clients
			 can be found at
www.oregon.gov/OHA/pharmacy/careassist/docs/bridgecodes.pdf
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-4000 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  431.962
Stats. Implemented: ORS
				  431.962
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-4005 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  431.962
Stats. Implemented: ORS
				  431.962 -
				  431.978 &
				  431.992
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-4010 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  431.962
Stats. Implemented: ORS
				  431.962 &
				  431.964
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-4015 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  431.962
Stats. Implemented: ORS
				  431.962
Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 121 - PHARMACEUTICAL SERVICES › Section 410-121-4020 - Renumbered

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  431.962
Stats. Implemented: ORS
				  431.962 &
				  431.966
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 410-122-0020 - Orders

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The purchase,
			 rental, or modifications of durable medical equipment and the purchase of
			 supplies must have an order from the prescribing practitioner prior to
			 dispensing items to a client.
(2)
			 For any durable medical equipment, prosthetics, orthotics and supplies
			 (DMEPOS), a provider must have a written order signed and dated by the
			 prescribing practitioner prior to submitting a claim to the Division.
(3) A provider may dispense some items based
			 on a verbal order from the prescribing practitioner, except those items
			 requiring a written order prior to delivery or as specified in a particular
			 rule:
(a) A provider must maintain
			 documentation of the verbal order and this documentation must be available to
			 the Division upon request;
(b) The
			 verbal order must include all of the following elements:
(A) Client's name;
(B) Practitioner's name;
(C) Description of the item;
(D) Start date of the order;
(E) Primary ICD-10 diagnosis code for the
			 equipment/supplies requested.
(c) For items that are dispensed based on a
			 verbal order, the provider must obtain a written order that meets the
			 requirements outlined below for written orders.
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 410-122-0040 - Prior Authorization

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Durable
			 Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) providers
			 shall obtain prior authorization (PA) for Healthcare Common Procedure Coding
			 System (HCPCS) Level II codes as specified in rule, unless otherwise
			 noted.
(2) Providers shall request
			 PA as follows (see the DMEPOS Supplemental Information for contact
			 information):
(a) For Medically Fragile
			 Children's Unit (MFCU) clients, from the Department of Human Services
			 (Department) MFCU;
(b) For clients
			 enrolled in a Coordinated Care Organization (CCO), from the CCO;
(c) For clients enrolled in a prepaid health
			 plan (PHP), from the PHP;
(d) For
			 all other clients, from the Health Systems Division.
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 410-122-0080 - Conditions of Coverage, Limitations, and Restrictions

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For clients under the age of 21: The
			 EPSDT program covers all medically necessary and medically appropriate services
			 needed to correct or ameliorate health conditions, or to improve the client's
			 ability to grow, develop, or participate in school, regardless of placement on
			 or inclusion in the Prioritized List of Health Services. Coverage for medical
			 equipment and supplies shall not be denied without an individual review for
			 medical necessity and medical appropriateness, as defined in OAR
			 410-151-0001.
(2) For clients age
			 21 and older: The Division may pay for durable medical equipment, prosthetics,
			 orthotics, and medical supplies (DMEPOS) when the item meets all criteria in
			 these rules, including all of the following conditions. The item:
(a) Is approved for marketing and registered
			 or listed as a medical device by the Food and Drug Administration (FDA), when
			 FDA approval is required for the item, and is otherwise generally considered to
			 be safe and effective for the intended purpose. In the event of delay in FDA
			 approval and registration, the Division shall review purchase options on a
			 case-by-case basis;
(b) Is
			 medically appropriate and medically necessary for the client, as defined in OAR
			 410-120-0000;
(c) Is primarily and
			 customarily used to serve a medical purpose;
(d) Is generally not useful to an individual
			 in the absence of medical disability, illness, or injury;
(e) Is suitable for use in a client's home or
			 any non-institutional setting in which normal life activities take
			 place;
(f) Specifically for durable
			 medical equipment, the item can withstand repeated use and can be reusable or
			 removable;
(g) Meets the coverage
			 criteria as specified in this division and subject to service limitations of
			 the Division rules;
(h) Is
			 requested in relation to a diagnosis and treatment pair that is above the
			 funding line and consistent with treatment guidelines on the Health Evidence
			 Review Commission's (HERC) Prioritized List of Health Services (Prioritized
			 List of Health Services or List);
(i) Is included in the Oregon Health Plan
			 (OHP) client's benefit package of covered services;
(j) Is the least costly, medically
			 appropriate item that meets the medical needs of the client;
(k) Coverage is not restricted to items
			 covered by the Medicare program.
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 410-122-0090 - Face-to-Face Encounter Requirements (for Fee-For-Service Clients)

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For initial
			 ordering of DME items identified in section (9) of this rule, an in-person or
			 telehealth face-to-face encounter that is related to the primary reason the
			 client requires the medical equipment or supplies must occur no more than six
			 months prior to the start of services.
(2) Telehealth encounters used to satisfy the
			 face-to-face encounter requirement for a DMEPOS item must meet the requirements
			 outlined in the HERC Ancillary Guideline note A5.
(3) The face-to-face encounter shall be
			 conducted and documented by one of the following practitioners:
(a) A physician;
(b) A nurse practitioner or clinical nurse
			 specialist, as authorized by State law;
(c) A physician assistant, as authorized by
			 and in accordance with State law;
(d) A licensed practitioner of the healing
			 arts acting within the scope of practice authorized under State law;
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 410-122-0180 - Healthcare Common Procedure Coding System Level II Coding

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Healthcare
			 Common Procedure Coding System (HCPCS) level II is a comprehensive and
			 standardized system that classifies similar products that are medical in nature
			 into categories for the purpose of efficient claims processing. For each
			 alphanumeric HCPCS code, there is descriptive terminology that identifies a
			 category of like items. These codes are used primarily for billing purposes.
			 The Centers for Medicare and Medicaid Services (CMS) maintain and distribute
			 HCPCS Level II Codes.
(2) HCPCS is
			 a system for identifying items and services. It is not a methodology or system
			 for making coverage or payment determinations. The existence of a code does
			 not, of itself, determine coverage for an item or service. While these codes
			 are used for billing purposes, decisions regarding the addition, deletion, or
			 revision of HCPCS codes are made independently of the process for making
			 coverage and payment determinations for medical items or services. Items billed
			 that do not have a HCPCS code will be reviewed by the Division on a
			 case-by-case basis to ensure rule 410-122-0080  is appropriately applied to item
			 billed.
(3) The Division uses the
			 HCPCS Level II Code Set to ensure that claims are processed in an orderly and
			 consistent manner.
(4) When
			 requesting authorization and submitting claims, DMEPOS providers must use these
			 codes to identify the items they are billing. The descriptor that is assigned
			 to a code represents the definition of the items and services that can be
			 billed using that code.
(5) This
			 rule division may not contain all code updates needed to report medical
			 services and supplies.
(6) For the
			 most up-to-date information on code additions, changes, or deletions, refer to
			 the fee schedule posted on the Division Web site.
(7) The Division fee schedule lists the
			 current HCPCS codes in an alphanumeric index.
(8) Newly established temporary codes and
			 effective dates for their use are also posted on the Division website at
www.oregon.gov/OHA/HSD/OHP/Pages/Fee-Schedule.aspx
.
(9) CMS updates permanent national codes
			 annually on January 1st.
(10) CMS
			 may add, change, or delete temporary national codes on a quarterly
			 basis.
(11) The Medicare Pricing,
			 Data Analysis and Coding (PDAC) contractor is responsible for assisting DMEPOS
			 providers and manufacturers in determining which HCPCS code shall be used to
			 describe DMEPOS items.
Publications: Publications referenced are available from the
				  agency.
Statutory/Other Authority: ORS
				  413.042 & 414.065
Statutes/Other Implemented: ORS
				  413.042 &
				  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 410-122-0182 - Legend

Current through Register Vol. 63, No. 7, July 1, 2024
This rule is retroactive and applies to services rendered on or
				after Jan. 1, 2009.
(1) The Division
			 uses abbreviations in the tables within this division.
(2) This rule explains the meaning of these
			 abbreviations.
(3) PA - Prior
			 authorization (PA): "PA" indicates that PA is required, even if the client has
			 private insurance. See OAR 410-122-0040  for more information about PA
			 requirements.
(4) PC - Purchase:
			 "PC" indicates that purchase of this item is covered for payment by the
			 Division.
(5) RT - Rent: "RT"
			 indicates that the rental of this item is covered for payment by the
			 Division.
(6) MR - Months Rented:
(a) "13" - Indicates up to 13 consecutive
			 months of continuous rental, when the Division fee schedule purchase price is
			 met for the item, when the usual purchase price is reached or the actual charge
			 is met (whichever is lowest), the equipment is considered paid for and owned by
			 the client. The provider must then transfer title of the equipment to the
			 client;
(b) For any other rental
			 situation, where the Division fee schedule lists a purchase price and this
			 purchase price is met for the item, when the usual purchase price is reached or
			 the actual charge is met (whichever is lowest), the equipment is considered
			 paid for and owned by the client. The provider must then transfer title of the
			 equipment to 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 410-122-0184 - Repairs, Servicing, Replacement, Delivery, and Dispensing

Current through Register Vol. 63, No. 7, July 1, 2024
(1) For indications
			 and limitations of coverage and medical appropriateness, the Division may cover
			 reasonable and necessary repairs, servicing, and replacement of medically
			 appropriate, covered durable medical equipment, prosthetics, and orthotics,
			 including those items purchased or in use before the client enrolled with the
			 Division:
(a) Repairs:
(A) To repair means to fix or mend and to put
			 the equipment back in good condition after damage or wear to make the equipment
			 serviceable;
(B) If the expense for
			 repairs exceeds the estimated expense of purchasing or renting another item of
			 equipment for the remaining period of medical need, no payment may be made for
			 the amount of the excess;
(C)
			 Payment for repairs is not covered when:
(i)
			 The skill of a technician is not required;
(ii) The equipment has been previously
			 denied;
(iii) Equipment is being
			 rented, including separately itemized charges for repair;
(iv) Equipment, parts and labor are covered
			 under a manufacturer's or supplier's warranty.
(D) Code K0739 may not be used on an initial
			 claim for equipment. Payment for any labor involved in assembling, preparing,
			 or modifying the equipment on an initial claim is included in the allowable
			 rate.
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 410-122-0186 - Payment Methodology

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The
			 Division utilizes a payment methodology for covered durable medical equipment,
			 prosthetics, orthotics and supplies (DMEPOS) that is generally based on the
			 2012 Medicare fee schedule:
(a) The Division
			 fee schedule amount is 82.6 percent of 2012 Medicare Fee Schedule for items
			 covered by Medicare and the Division, except for:
(A) Ostomy supplies fee schedule amounts are
			 93.3 percent of 2012 Medicare Fee Schedule (See Table 122-0186-1 for list of
			 Ostomy codes subject to this pricing); and
(B) Prosthetic and Orthotic fee schedule
			 amounts (L-codes) are 82.6 percent of 2012 Medicare Fee Schedule; and
(C) Complex Rehabilitation items and services
			 other than power wheelchairs, fee schedule amounts are 88 percent of 2012
			 Medicare Fee Schedule (See Table 122-0186-2 for list of Complex Rehabilitation
			 codes subject to this pricing); and
(D) Group 1 power wheelchairs (K0813-K0816)
			 and Group 2 power wheelchairs with no added power option (K0820-K0829) fee
			 schedule amounts are 55 percent of 2012 Medicare Fee Schedule;
(E) Group 3 power wheelchairs (K0835-K0864)
			 fee schedule amounts are 58.7 percent of 2012 Medicare Fee Schedule;
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 410-122-0187

Current through Register Vol. 63, No. 7, July 1, 2024
Stat. Auth.: ORS
				  414.065 & HB 4108
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 410-122-0188 - DMEPOS Rebate Agreements

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 The Health Systems Division has a Centers for Medicare and Medicaid Services
			 (CMS) approved DMEPOS Rebate Agreement.
(2) The Division negotiates DMEPOS Rebate
			 Agreements for specific products through the Sovereign States Drug Consortium
			 (SSDC) multi-state pool and DMEPOS manufacturers. Negotiations are
			 confidential, and shall not be disclosed, except in connection with an
			 agreement/contract or as may be required by law. Confidentiality is required of
			 any third party involved in administration of the agreement/contract.
(3) Manufacturers may submit rebate offers
			 for consideration to include their product(s) on the Preferred DME List
			 (PDMEL), after gaining access to the SSDC secure web-based offer entry
			 system.
(4) Manufacturers must
			 abide by requirements of the SSDC.
(5) The PDMEL shall consist of DMEPOS that
			 the Food and Drug Administration (FDA) has determined to be safe and
			 effective
(6) Upon acceptance of
			 the offer:
(a) The SSDC will notify
			 manufacturers of the status of their offer(s);
(b) Supplemental Agreements will be executed
			 after signed by all parties, approved by CMS if required, and products may be
			 added to the PDMEL;
(c) The
			 Division may contract for the functions of tracking utilization, invoicing, and
			 dispute resolution for rebate products.
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 410-122-0200 - Pulse Oximeter for Home Use

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 tamper-proof pulse oximeter for home use when all of the following
			 criteria are met:
(A) The client has
			 frequently fluctuating oxygen saturation levels that are clinically
			 significant;
(B) Measurements are
			 integral in dictating acute therapeutic intervention;
(C) The absence of readily available
			 saturation measurements represents an immediate and demonstrated health
			 risk;
(D) The client has a
			 caregiver trained to provide whatever care is needed to reverse the low oxygen
			 saturation level ordered by the practitioner;
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 410-122-0202 - Positive Airway Pressure (PAP) Devices for Adult Obstructive Sleep Apnea

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division
			 may cover a positive airway pressure (PAP) device for treatment of obstructive
			 sleep apnea (OSA) when:
(a) The client has a
			 face-to-face clinical evaluation by the treating practitioner prior to a sleep
			 test to assess the client for obstructive sleep apnea; and
(b) The client has a polysomnogram performed
			 in a facility-based laboratory or a home sleep test that demonstrates positive
			 diagnosis of OSA with either of the following:
(A) The apnea-hypopnea index (AHI) or
			 Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per
			 hour; or
(B) The AHI or RDI is
			 between 5 and 14 events with additional symptoms including one or more of the
			 following:
(i) Excessive daytime sleepiness as
			 documented by a score of greater than 10 on the Epworth Sleepiness Scale or
			 daytime sleepiness interfering with ADLs that is not attributable to another
			 modifiable sedating condition (e.g. narcotic dependence); or
(ii) Documented hypertension; or
(iii) Ischemic heart disease; or
(iv) History of stroke.
(c) The client or their caregiver
			 has received instruction from the supplier of the PAP device and accessories in
			 the proper use and care of the equipment.
(d) The client meets criteria listed in
			 section (2) of this rule for the particular device to be used.
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 410-122-0204 - Nebulizer

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications and
			 limitations of coverage and medical appropriateness:
(a) Equipment:
(A) Small volume nebulizer:
(i) A small volume nebulizer (A7003, A7004,
			 A7005) and related compressor (E0570) may be covered to administer inhalation
			 drugs based on evidence-based clinical practice guidelines;
(ii) The practitioner shall have considered
			 use of a metered dose inhaler (MDI) with and without a reservoir or spacer
			 device and decided that, for medical reasons, the MDI was not sufficient for
			 the administration of needed inhalation drugs.
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 410-122-0205 - Respiratory Assist Devices

Current through Register Vol. 63, No. 7, July 1, 2024
(1) As
			 referenced in this policy, non-invasive positive pressure respiratory
			 assistance (NPPRA) is the administration of positive air pressure, using a
			 nasal and/or oral mask interface which creates a seal, avoiding the use of more
			 invasive airway access (e.g., tracheostomy).
(2) Indications and Coverage - General:
(a) The "treating prescribing practitioner"
			 must be one who is qualified by virtue of experience and training in
			 non-invasive respiratory assistance, to order and monitor the use of
			 respiratory assist devices (RAD);
(b) For the purpose of this policy,
			 polysomnographic studies must be performed in a sleep study laboratory, and not
			 in the home or in a mobile facility. The sleep study laboratory must comply
			 with all applicable state regulatory requirements;
(c) For the purpose of this policy, arterial
			 blood gas, sleep oximetry and polysomnographic studies may not be performed by
			 a durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)
			 provider. For purposes of this policy's coverage and payment guidelines, a
			 DMEPOS provider is not considered a qualified provider or supplier of these
			 tests;
(d) If there is
			 discontinuation of usage of E0470 or E0471 device at any time, the provider is
			 expected to ascertain this, and stop billing for the equipment and related
			 accessories and supplies.
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 410-122-0206 - Intermittent Positive Pressure Breathing

Current through Register Vol. 63, No. 7, July 1, 2024
E0500, IPPB machine, all types, with built-in nebulization;
				manual or automatic valves; internal or external power source the Division of
				Medical Assistance Programs (Division) will rent. Covered if medically
				appropriate for the following indications:
(1) Clients at risk of respiratory failure
			 because of decreased respiratory function secondary to kyphoscoliosis or
			 neuromuscular disorders.
(2)
			 Clients with severe bronchospasm or exacerbated chronic obstructive pulmonary
			 disease (COPD) who fail to respond to standard therapy.
(3) The management of atelectasis that has
			 not improved with simple therapy.
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 410-122-0207 - Respiratory Supplies

Current through Register Vol. 63, No. 7, July 1, 2024
Table 122-0207.
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 410-122-0208 - Suction Pumps

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications and
			 Limitations of Coverage:
(a) Use of a home
			 model respiratory suction pump may be covered for a client who has difficulty
			 raising and clearing secretions secondary to:
(A) Cancer or surgery of the throat or mouth;
			 or
(B) Dysfunction of the
			 swallowing muscles; or
(C)
			 Unconsciousness or obtunded state; or
(D) Tracheostomy; or
(E) Neuromuscular conditions;
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 410-122-0209 - Tracheostomy Care Supplies

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Indications and Coverage: For a client following an open surgical tracheostomy
			 which has been open or is expected to remain open for at least three
			 months.
(2) Documentation: A
			 prescription for tracheal equipment which is signed by the prescribing
			 practitioner must be kept on file by the DMEPOS provider. The prescribing
			 practitioner's records must contain information which supports the medical
			 appropriateness of the item ordered.
(3) Procedure Codes -- Table
			 122-0209.
Tables referenced are available from the
				  agency.
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 410-122-0210 - Ventilators

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Indications and
			 limitations of coverage:
(a) Mechanical
			 ventilatory support may be provided to a client for the purpose of life support
			 during therapeutic support of suboptimal cardiopulmonary function, or
			 therapeutic support of chronic ventilatory failure;
(b) A ventilator may be covered by the
			 Division for treatment of neuromuscular diseases, thoracic restrictive
			 diseases, and chronic respiratory failure consequent to chronic obstructive
			 pulmonary disease. This includes both positive and negative pressure
			 types;
(c) A ventilator for
			 pediatric home ventilator management may be covered on a case-by-case basis
			 based on medical appropriateness, evidence-based medicine and best health
			 practices.
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 410-122-0211 - Cough Stimulating Device

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Indications and Limitations of Coverage and Medical Appropriateness: The
			 Division of Medical Assistance Programs (Division) may cover a cough
			 stimulating device, alternating positive and negative airway pressure for a
			 client who meets the following criteria:
(a)
			 The client has been diagnosed with a neuromuscular disease as identified by one
			 of the following diagnosis codes:
(A) Late
			 effects of acute poliomyelitis;
(B) Cystic fibrosis;
(C) Werdnig-Hoffmann disease-anterior horn
			 cell disease unspecified;
(D)
			 Multiple sclerosis - quadriplegia and quadriparesis;
(E) Myoneural disorders;
(F) Disorders of diaphragm;
(G) Fracture of vertebral column, cervical,
			 or dorsal (thoracic);
(H) Late
			 effect of spinal cord injury;
(I)
			 Late effect of injury to a nerve root or roots, spinal plexus or plexuses and
			 other nerves of trunk;
(J) Spinal
			 cord injury without evidence of spinal bone injury, cervical or dorsal
			 (thoracic); and
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 410-122-0220 - Pacemaker Monitor

Current through Register Vol. 63, No. 7, July 1, 2024
(1) E0610 -
			 Pacemaker monitor, self-contained, checks battery depletion, includes audible
			 and visible check systems:
(a) The Division of
			 Medical Assistance Programs (Division) will purchase;
(b) Also covered for payment by the Division
			 when client is a resident of a nursing facility.
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 410-122-0240 - Apnea Monitors for Infants

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Indications and limitations of coverage and medical appropriateness:
(a) For infants less than twelve (12) months
			 of age with documented apnea, or who have known risk factors for
			 life-threatening apnea, the Division may cover home apnea monitors and related
			 supplies for any of the following indications:
(A) Up to three (3) months for:
(i) Apnea of prematurity: Sudden cessation of
			 breathing that lasts for at least 20 seconds, is accompanied by bradycardia
			 (heart rate less than 80 beats per minute), or is accompanied by oxygen
			 desaturation (O2 saturation less than 90 percent or cyanosis) in an infant
			 younger than 37 weeks gestational age;
(ii) Apparent life-threatening event (ALTE):
			 An episode that is characterized by some combination of apnea (central or
			 occasionally obstructive), color change (usually cyanotic or pallid but
			 occasionally erythematous or plethoric), marked change in muscle tone (usually
			 marked limpness), choking, or gagging;
(iii) Documented gastroesophageal reflux
			 disease (GERD) that results in apnea, bradycardia, or oxygen
			 desaturation;
(iv) Documented
			 prolonged apnea of greater than 20 seconds in duration;
(v) Documented apnea accompanied by
			 bradycardia to less than 80 beats per minute;
(vi) Documented apnea accompanied by oxygen
			 desaturation (below 90 percent), cyanosis, or pallor;
(vii) Documented apnea accompanied by marked
			 hypotonia;
(viii) When off
			 medication for bradycardia previously treated with caffeine, theophylline, or
			 similar agents;
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 410-122-0250 - Breast Pumps

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 breast pump for
			 postpartum women when a pump is necessary to establish or maintain milk
			 production in order to maximize availability of breast milk to the
			 baby;
(b) For cases in which there
			 is a medical indication for breast pumps, the pumps shall be supplied whenever
			 possible within 24 hours to allow for continued milk production;
(c) A breast pump shall not be provided until
			 a need is determined following birth;
(d) A breast pump shall not be provided if it
			 is known that mother is using a substance that is contraindicated while
			 breastfeeding and does not plan to stop its use;
(e) Reimbursement for a single-user electric
			 breast pump (E0603) includes all parts necessary for pumping. A separate kit is
			 not needed or separately reimbursable;
(f) The following services are not covered:
(A) Accessories;
(B) An electric breast pump for the comfort
			 and convenience of the mother;
(C)
			 Supplemental Nutrition System (SNS);
(D) Heavy duty, hospital grade breast
			 pumps;
(E) Replacement
			 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 410-122-0260 - Home Uterine Monitoring

Current through Register Vol. 63, No. 7, July 1, 2024
(1)
			 Home uterine monitoring (S9001) requires prior authorization (PA) and may be
			 approved for the following conditions:
(a)
			 Pre-term labor with one or more of the following complications:
(A) Incompetent cervix;
(B) Cervical cerclage;
(C) Polyhydramnios;
(D) Anomalies of the uterus;
(E) History of cone biopsy;
(F) Cervical dilation or effacement;
(G) Unknown etiology.
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 410-122-0280 - Heating/Cooling Accessories

Current through Register Vol. 63, No. 7, July 1, 2024
Procedure Codes for Heating/Cooling Accessories: Table
				122-0280.
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 410-122-0300 - Light Therapy

Current through Register Vol. 63, No. 7, July 1, 2024
(1) The Division
			 may cover home phototherapy when medically appropriate and for the following
			 conditions:
(a) For a term or near-term infant
			 whose elevated bilirubin is not due to a primary hepatic disorder or other
			 hemolytic disorder that requires inpatient care and the American Academy of
			 Pediatrics Clinical Practice Guidelines for management of hyperbilirubinemia
			 with phototherapy are met; The Practice Guidelines are available at
https://publications.aap.org/pediatrics/article/150/3/e2022058859/188726/Clinical-Practice-Guideline-Revision-Management-of?autologincheck=redirected
(b) For severe inflammatory skin conditions
			 identified in the Health Evidence Review Commission's Prioritized List of
			 Health Services, guideline note 21.
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 410-122-0320 - Manual 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 manual
			 wheelchair 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 eating,
			 toileting, grooming, dressing, and bathing. A mobility limitation is one that:
(i) Prevents the client from accomplishing an
			 MRADL entirely;
(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.