Regulation .05 Limitations.
Regulation .05 Limitations.LinkCopy Citation
A.
The Program does not cover:
(1)
Any service or items not identified in Regulation .04 of this chapter;
(2)
Demurrage;
(3)
Charges for delivery;
(4)
Equipment prescribed primarily to provide comfort or convenience, including, but not limited to, air conditioners and room humidifiers;
(5)
Items which are investigational or experimental in nature;
(6)
Oxygen and related equipment not for pulmonary use;
(7)
Pre-set oxygen for emergency use;
(8)
Trach string or tape.
B.
The Program places the following limitations upon covered services:
(1)
Reimbursement for aerosol equipment will only be provided if a hand held nebulizer has been tried and is not successful, as indicated in the clinical summary;
(2)
Reimbursement for IPPB machine will only be authorized if the aerosol compressor with the nebulizer kit has been tried and is not successful, as indicated in the clinical summary;
(3)
Reimbursement may not be made for:
(a)
Repairs or replacement parts for rented items;
(b)
Oxygen prescribed on an as-needed basis (PRN);
(c)
Oxygen prescribed for stand-by purposes;
(d)
Piped-in oxygen;
(e)
Oxygen and related respiratory equipment and services provided in a facility or by a group when reimbursement is covered by another segment of the Program; and
(4)
Payment for portable oxygen will be made only when:
(a)
It is required in the pursuit of medical treatment; and
(b)
The medical necessity is indicated for this type of system.