Page 134 - Business Development Orientation Binder
P. 134
Critical DME
Attachment A
Critical DME Payer criteria (Medicare) Clinical and safety criteria that determine
“critical”
Compressor nebulizer Medically necessary to administer MEDs Medication via inhaler ordered; no
for COPD, Asthma - other manual alternate method of delivery available (e.g.
neb/metered dose inhaler must be tried Manual inhaler), and
first (Medicare). Patient at risk for adverse outcome if
medication not provided. E.g. Asthma
Compressor heavy duty Above plus pt requires humidity due to Same as payer criteria.
heavy secretions – must have trach.
(continuous aerosol for constant mist to
trach)
Nebulizer (use with regulator/flowmeter) Patient has O2 therapy &requires Same as payer criteria
humidification of oxygen in conjunction w
heavy duty compressor
Portable O2 system Required for ambulation within the home Same as payer criteria for stationary 02
system.
Serve as back up for stationary system.
Stationary 02 system PO2 55 or less, SAO2 below 89 test Same as payer criteria for stationary 02
performed w/in 2 days prior to order. system.
Note: obtain pulse oximetry reading in
home if necessary.
Pressure mattress (alternating pressure or Multiple stage 2 or stage 3 decubitus – Bedbound , and wounded with pressure
low air loss) LMN support statement required before ulcers or post flap
dispensing
Pressure pad/alternating with pump Stage 1 or prevention for patient at high Bedbound , and wounded with pressure
risk of breakdown ulcers or post flap
Enteral Nutrition Products and Pump Sole source of nutrition Patient has dysphagia cannot swallow –
Long term (> 3 months) dysfunction of
structures that permit food to reach small
bowel or disease which impairs digestion
that requires tube feeding to maintain
patients weight.
Receives nutrition from a feeding tube
Suction pump Required for patients who have difficulty As per payer criteria
raising and clearing secretions secondary
to other condition (trach, surgery, cancer,
dysfunction of swallowing muscles) 12
caths/month without trach, 3/day with
trach
Hospital bed (fixed or variable height/with CMN – medical condition requires Patient is:
side rails). Manual controls. positioning not feasible in ordinary bed – Bedbound, and
to alleviate pain, and or head required to Wounded with pressure ulcers.
be elevated > 30 degrees, or traction
required, and requires frequent change in
body position (need cardiac and or
respiratory condition for elect bed.)
Jay cushion CMN required before dispensing – must Patient is:
be highly susceptible (must have a Chair bound, and
wheelchair) who provided it, when, who Wounded with pressure ulcers
was billed.
ROHO cushion Highly susceptible - CMN required before Patient is:
dispensing Chair bound, and
Wounded with pressure ulcers
Wheelchair cushion, 2, 3 or 4 inch Patient must have a wheelchair (no Patient is:
cushion ordered previously) Chair bound, and
Wounded with pressure ulcers
1
