(A) Compression garments.
(1) Compression garments are specialized garments prescribed for ambulatory persons with diagnoses listed under paragraph (A)(2) of this rule. Compression garments must be obtained through prior authorization. Only compression garments equal to or greater than 18mm Hg. will be considered for approval. All prior authorization requests for compression garments must contain the manufacturer and catalogue number.
(2) Coverage of compression garments is limited to the following diagnoses:
(c) Milroy's disease.
(d) Orthostatic hypotension.
(e) Pregnancy with associated symptomatic venous insufficiency.
(f) Stasis dermatitis.
(g) Stasis ulcers.
(h) Symptomatic chronic venous insufficiency (for example, pain, swelling, ulcers, severe varicose veins).
(j) Post-thrombotic syndrome.
(B) Surgical stockings are specialized stockings covered when ordered by a prescriber to prevent embolisms in the legs of non-ambulatory (e.g., bed-confined) consumers. Surgical stockings are used as a short-term treatment (up to three months) after a surgical event. Surgical stockings must be obtained through prior authorization. If required for treatment during an inpatient hospital stay or outpatient hospital visit, the product will be reimbursed in accordance with Chapter 5101:3-2 of the Administrative Code.
(C) Compression burn garments are covered only when they are used to reduce hypertrophic scarring and joint contractures following a burn injury. Compression burn garments must be obtained through prior authorization.
(D) Providers fitting and dispensing compression garments, surgical stockings, or compression burn garments that are custom-made or custom-fitted must be certified to do so according to industry standards. A provider will not be eligible for reimbursement for custom-made or custom-fitted garments if the provider does not have a certified fitter on staff or under contract. Providers must keep on file documentation subject to review by ODJFS verifying that they have a trained fitter on staff or under contract.
(E) In addition to a fully completed prior authorization form JFS 03142 (rev. 2/2003), a fully completed form JFS 01905 (11/2006), "Certificate of Medical Necessity/Prescription Compression Garments (CMN)" (appendix A to this rule) that is signed and dated no more than thirty days prior to the first date of service must be submitted for prior authorization before reimbursement for compression garments, surgical stockings, or compression burn garments will be considered.
R.C. 119.032 review dates: 09/27/2006 and 01/01/2012
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01, 5111.02, 5111.021
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/1/80, 3/1/84, 10/1/88