DME Insurance Coverage

DME Insurance Coverage This guide is designed to streamline the process for healthcare professionals to prescribe medical supplies to patients. This booklet lists required documentation to ensure medical equipment is received by patients faster and covered by medical insurance. All required documentation needs to be noted on the patient’s chart or medical record and attached with the prescription. Kohll’s R X Locations and Services Pharmacy and Respiratory Experts 2915 Leavenworth St, Omaha, NE 68105 | Phone: 402-342-6547 | Fax: 402-341-5207 Millard Pharmacy and Wheelchair Specialists 12741 Q St, Omaha, NE 68137 | Phone: 402-408-1990 | Fax: 402-895-3155 Midtown Pharmacy 5002 Dodge St, Omaha, NE 68132 | Phone: 402-553-8900 | Fax: 402-553-0170 Papillion Pharmacy 1413 S Washington St, Suite 125, Papillion, NE 68046 | Phone: 402-331-8632 | Fax: 402-331-8695 Lincoln Pharmacy 808 N 27th St, Lincoln, NE 68503 | Phone: 402-476-3342 | Fax: 402-476-3586 Malvern Pharmacy 403 Main St, Malvern, IA 51551 | Phone: 712-624-9050 | Fax: 712-624-9042 Table of Contents General DME Prescription Requirements 3 Respiratory Nebulizers 4 CPAP and BIPAP 4 Oxygen 5 Ventilators 6 Tracheostomy Care Supplies 6 Respiratory Assist Devices 6 Mechanical Insufflation/Exsufflation devices 7 Suction Pump 7 Mobility Care Canes and Crutches 8 Walkers 8 Manual Wheelchairs 9 Wheelchair Accessories 10 Wheelchair Seating/Cushions 10 Power Scooters and Power Wheelchairs 11 Home and Personal Care Commodes 12 Hospital Beds 12 Support Surfaces for Beds 13 Patient Lifts 14 Seat Lift Chairs 14 Orthopedic Footwear 14 Diabetic Shoes 15 Ostomy Supplies 15 Urological Supplies 16 Orthoses and Prostheses Ankle-Foot/Knee-Ankle-Foot orthoses 17 External Breast Prosthesis 17 Knee Orthosis 18 Spinal Orthoses 18 Wound Care Negative Pressure Wound Therapy Pumps 19 Surgical Dressings 20 TENS (Transcutaneous Electrical Nerve Stimulators) Units 21 Medications and Miscellaneous Enteral Nutrition 22 Glucose Monitors 22 Immunosuppressive Drugs 23 Oral Anticancer Drugs 23 Oral Antiemetic Drugs 23 2 | Table of Contents Kohll’s Rx Durable Medical Insurance Coverage Guide General DME Prescription Requirements Date of prescription Specific item(s) prescribed “walker misc.” is not the same as “4-wheeled walker” Diagnosis and/or diagnosis code (preferred) Length of need Physician signature Wet or electronic; no stamp Quantity (if applicable) Replacement schedule (if applicable) Additionally: Chart notes with item-specific requirements documented and attached to prescription General DME Prescription Requirements | 3 Kohll’s Rx is more than a pharmacy, we are a one stop resource Respiratory Supplies Nebulizers A nebulizer is required to administer medications for one or more the following conditions: | Obstructive pulmonary disease | Cystic fibrosis | Bronchiectasis | HIV | Pneumocystosis | Complications of organ transplantation Include facemasks, tubing, and nebulizer kit with each prescription, including refills | Refills: – Disposable equipment needs replacement 2 times per month – Reusable equipment needs replacement 2 times per 6 months EFFECTIVE CHART NOTE EXAMPLE Nebulizer is needed to administer Albuterol for COPD. CPAP and BIPAP Initial coverage – first 3 months | Face to Face appointment to establish OSA AND | Sleep test either at home or through a sleep study | Document if the patient has any of the following symptoms or conditions: – Excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, IHD, or history of stroke Reevaluating after failing a 3–month trial | Face to Face reevaluation as to why and repeat sleep test BIPAP | Document failure of CPAP during an in–facility study or at home using optimal therapy | Used CPAP for more than 3 months Continued Coverage – Needs to show that patient is benefiting | Face to face reevaluation between 30 and 90 days after starting therapy to document improvement in OSA AND | Document adherence – Use device >4 hours per night, 70% of the time during a month Replacement – After 5 years of use, need a Face to Face evaluation Non–heated or heated humidifier – Needs order for the type of humidifier 4 | Respiratory Supplies Kohll’s Rx Durable Medical Insurance Coverage Guide EFFECTIVE CHART NOTE EXAMPLE John Doe has been experiencing excessive daytime sleepiness and insomnia the past 30 days. During the in–clinic sleep study, the patient had a Respiratory Disturbance Index of 19 events per hour, with a total of 42 events during the night. Oxygen Medical records REQUIRE | Severe lung disease or hypoxia-related symptoms requiring oxygen AND | Blood gas study performed | Alternative treatments deemed ineffective Group I Criteria — 12 months of coverage | ABG < 55 mmHg or O2 sat <88% – Taken in one of the following settings – At rest – 3 exercise studies – 5 minutes while sleep Group II criteria — 3 months of coverage | ABG between 56-59, O2 sat at 89% in same testing settings as Group I | The patient has one of the following: – Dependent edema – Pulmonary hypertension – Erythrocythemia with hematocrit >56% Portable O2 Systems | Documented in the chart that the patient is mobile within the home | AND BGS performed at rest or during exercise EFFECTIVE CHART NOTE EXAMPLE John Doe has COPD. SP02 at rest was 85% with the SP02 in the room at 90%. The patient performed a 6-minute walk test in the same room of SP02 at 90%, and SP02 of the patient was 86%. Per patient history, has been on combination inhaler therapy and steroid therapy without improvement. Respiratory Supplies | 5 Kohll’s Rx is more than a pharmacy, we are a one stop resource Ventilators The patient must have one or more of the following: | Neuromuscular disease | Thoracic restrictive disease | Chronic respiratory failure due to COPD Define a patient-specific treatment plan and provide a necessity for ventilator for disease | Specific details on medical record to support the use of the selected ventilator | If patient does not use respiratory support it can lead to harm or death. Non-invasive ventilators | ABG pCO2 >52 mmHg | Pulmonary function test with FVC <50% | Proof of failed BIPAP use | More than 2 hospitalizations within the past 12 months due to respiratory insufficiency Will not be covered for OSA Tracheostomy Care Supplies Has open surgical tracheostomy AND expected to be open for 3 or more months For a cleaning starter kit | Tracheostomy is <2 weeks old For care kit – tracheostomy is >2 weeks old Respiratory Assist Devices Initial Coverage – 3 months The patient has daytime hypersomnolence, excessive fatigue, morning headache, cognitive dysfunction, dyspnea, AND one of the following disorders | Restrictive thoracic disorder due to neuromuscular disease with either – ABG PaCO2 >45 mmHg or O2 sat <88% for more than 5 minutes during the night | COPD – PaCO2 is >52 mmHg while awake AND O2 sat is <88% for 5 minutes or more during sleep – Rule out OSA | Central Sleep or Complex Sleep Apnea – Polysomnography used to diagnose CSA or CompSA – Document significant improvement of sleep-associated hypoventilation using the devices | Hypoventilation syndrome – PaCO2 >45 mmHg and FEV1/FVC >70% AND – PaCO2 worsens by 7 mmHg or more during sleep OR PSG shows O2sat <88% for more than 5 minutes of nocturnal recording 6 | Respiratory Supplies Kohll’s Rx Durable Medical Insurance Coverage Guide Continued Coverage Signed and dated physician statement after 2 months of starting device documenting the use of the device for 4 or more hours per day and progress of symptoms Replacement After 5 years, must have a Face to Face and a new prescription Ventilators with Noninvasive interfaces The patient has a neuromuscular disease, thoracic restrictive disease, or chronic respiratory failure because of COPD Mechanical In/Exsufflation Devices The patient has a neuromuscular disease The condition significantly impairs the chest wall/diaphragm and the patient cannot clear secretions Suction Pumps Gastric suction pump | The patient unable to empty gastric secretions normally Respiratory Suction Pump | Difficulty raising/clearing secretions because of – Cancer/surgery of throat or mouth OR dysfunction of oropharyngeal muscles – OR unconscious OR tracheostomy Tracheal Suction Catheters | The patient has tracheostomy AND requires a covered respiratory pump for tracheostomy suctioning Closed System Catheters | The patient has tracheostomy AND requires covered respiratory pump AND covered ventilator Sterile Saline Solution | Documented to clear a suction catheter following tracheostomy suctioning Respiratory Supplies | 7 Kohll’s Rx is more than a pharmacy, we are a one stop resource mobility care Canes and Crutches The patient completely cannot perform an activity of daily living, is at risk for harm without assistance, or cannot complete the activity in a timely manner | The patient is unable to stand in order to dress or mobilize to the restroom The patient can safely use the cane/crutch The patient can benefit from using the cane/crutch NOT COVERED BY INSURANCE: Underarm, articulating, spring assisted crutches are not covered by insurance because they are deemed not reasonable and necessary (medical necessity has not been established) White cane for blind people is considered a “self-help” item and therefore not covered Walkers The patient cannot perform an activity of daily living, is at risk for harm without assistance, or cannot complete the activity in a timely manner The patient is able to safely use a walker AND prove that the walker will improve

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