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Ohio Administrative Code (Last Updated: January 12, 2021) |
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5160 Medicaid |
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Chapter5160-10. Medical Supplies, Durable Medical Equipment, Orthoses, and Prosthesis Providers |
5160-10-19. DMEPOS: positive airway pressure devices
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(A) Definition. "Apnea-hypopnea index (AHI)" is the mean number of episodes of apnea or hypopnea per hour recorded over a period of at least two hours without the use of a positive airway pressure device, reported by polysomnogram. The AHI may not be extrapolated or projected.
(B) Coverage.
(1) The default certificate of medical necessity (CMN) form is the ODM 01903, "Certificate of Medical Necessity: Positive Airway Pressure Devices" (rev. 7/2018). The CMN must include the following information:
(a) A diagnosis of obstructive sleep apnea;
(b) The results of a sleep study comprising components for diagnosis and titration, performed either separately as two studies or consecutively as a split study; and
(c) An estimated length of need.
(2) Payment for a positive airway pressure device may be made only if the following criteria are met:
(a) The diagnosis component of the sleep study, performed during at least two hours of recorded sleep without a positive airway pressure device, yields the following results:
(i) An AHI of at least fifteen; or
(ii) An AHI of at least five coupled with documented evidence of any of the following conditions:
(a) Excessive sleepiness during waking hours;
(b) Insomnia;
(c) Mood disorder;
(d) Impaired cognition;
(e) Hypertension;
(f) Ischemic heart disease; or
(g) A history of stroke.
(b) The titration component of the sleep study, performed with a positive airway pressure device, yields the following results:
(i) A decrease in the number of airway obstructions per hour; and
(ii) At least one of the following indications of effectiveness:
(a) An absolute increase in oxygen saturation to at least eighty-nine per cent;
(b) A relative increase in oxygen saturation of at least fifteen per cent; or
(c) Other clinical improvement recognized by the department.
(3) Payment for a variable or bilevel positive airway pressure device (i.e., a positive airway pressure device that produces different inspiratory and expiratory pressure levels) may be made only if the following criteria are met:
(a) A positive airway pressure device that produces a single pressure level has been tried and found to be ineffective; and
(b) Evidence gathered during the titration component of the sleep study or during a one-week trial period indicates that a variable or bilevel positive airway pressure device is effective.
(4) A need for oxygen is established if a positive airway pressure device is effective during a sleep study only when supplemental oxygen is administered simultaneously. That need for oxygen is presumed to last as long as the need for the positive airway pressure device, and no further sleep study is required to confirm a continued need for oxygen.
(C) Constraint. The provider of a positive airway pressure device may not perform the qualifying sleep study.