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This website publishes administrative rules on their effective dates, as designated by the adopting state agencies, colleges, and universities.

Rule 5160-10-17 | DMEPOS: pneumatic compression devices and accessories.

 

(A) Payment may be made directly to a provider for a pneumatic compression device or a related accessory only if the equipment and supplies are used to treat either lymphedema in the extremities or chronic venous insufficiency (CVI) with venous stasis ulcers. Accessories used for pneumatic compression of the chest or trunk are not covered. Before prescribing a pneumatic compression device, a practitioner must have found either that there was no significant improvement or that significant symptoms persisted when one of the following treatments was applied:

(1) For lymphedema in the extremities, four weeks of therapy involving the use of an appropriate compression bandage system or compression garment (either prefabricated or custom-fabricated), exercise, and elevation of the limb; or

(2) For CVI, six months of therapy involving the use of an appropriate compression bandage system or compression garment, appropriate wound dressings, exercise, and elevation of the limb.

(B) Payment may be made for the purchase of a pneumatic appliance. Payment may be made on a rental/purchase basis for a pneumatic compressor.

(C) The default form is the ODM 02929, "Certificate of Medical Necessity: Pneumatic Compression Devices and Accessories" (rev. 7/2018). The CMN must include the following information:

(1) A statement that previous treatment produced no significant improvement or that significant symptoms persisted;

(2) The date of the most recent evaluation;

(3) Identification by diagnosis code of the condition or conditions necessitating a pneumatic compression device;

(4) The expected length of time (expressed as the number of months or as 'lifetime') during which the individual will need the pneumatic compression device;

(5) A listing of symptoms observed, measurements taken, and any other data that serve to establish the severity of the condition or conditions;

(6) Specification of the pneumatic compression device and any accessories to be supplied;

(7) Documentation of the individual's clinical response to treatment during evaluation (including changes in measurement results);

(8) A brief summary of the treatment plan, including the pressure to be used, the frequency and duration of use, and a provisional monitoring schedule;

(9) An assessment of the individual's capacity for tolerating the prescribed treatment; and

(10) A statement about the ability of the individual (or someone authorized to assist the individual) to use the device correctly and consistently.

(D) The initial rental of a pneumatic compression device starts a trial period of at least thirty days and not more than ninety days. If the prescriber determines during this trial period that the device satisfactorily meets the individual's needs, then the provider may obtain a revised CMN during the trial period. Unless the expected length of need is so short that additional rental would cost less than purchase, the revised CMN will automatically be considered to support purchase of the device.

Supplemental Information

Authorized By: 5164.02
Amplifies: 5164.02
Five Year Review Date: 7/16/2023
Prior Effective Dates: 1/7/2010