La. Admin. Code tit. 40 § I-4509

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-4509 - Covered Services

A. All equipment, supplies and related services must be pre-authorized for reimbursement to be made. Services and equipment must be provided by providers who have qualified professional support staff to install and monitor the equipment, such as registered nurses, licensed practical nurses, or certified respiratory therapists. The claimant's authorized physician must prescribe continuous oxygen based upon the physician's interpretation of a blood oxygen report (i.e., arterial blood gas or oximetry) that was performed no more than 12 months prior to the authorization request. On occasion, a pulmonologist consultation may be requested. An annual blood oxygen analysis report is recommended for continued authorization of oxygen therapy.

B. Standard Oxygen Systems Versus Oxygen Concentrators. Oxygen concentrators will be considered only for claimants who require continuous daily oxygen for a minimum of 8 hours in a 24-hour period. Prior authorization requests to deliver more than standard amounts of oxygen will be reviewed by the carrier/self-insured employer with the requesting physician to determine if an oxygen concentrator would be a better option.

C. Portable Oxygen. At the request of the prescribing physician, the carrier/self-insured employer may authorize portable oxygen in three instances:

1. as a back up to an oxygen concentrator for claimants on continuous oxygen who need oxygen to go for routine medical treatment or visits;

2. for those claimants whose record documents eight or more hours of daily activity; and

3. when requested by the attending physician and approved by the carrier/self-insured employer for certain rehabilitation and recreational uses.

D. Miscellaneous Respiratory Equipment. Intermittent Positive Pressure Breathing (IPPB) machines, nebulizers, humidifiers, vaporizers and suction pumps are covered when prescribed by the treating physician of record.

E. Supplies. Those supplies directly related to the functioning or patient's usage of the respiratory equipment should be itemized along with the equipment in the same authorization request. These supplies should be billed using the codes listed in the "Schedule of Maximum Allowances" section of this manual.

F. Equipment Rental/Purchase Guidelines

1. Whenever the total of prospective rental payments for the period of medical need as stated by the prescribing physician equals or exceeds the maximum allowable purchase price, the provider should request a purchase instead of a rental in his/her prior authorization request. All new items with a maximum allowable rate of $150 or less and used items with an approved resale value quotation of $150 or less will be allowed as purchases only, regardless of the expected period of medical need.

2. If however, a definite period of medical need cannot be determined at the time of the initial request, a rental authorization will be granted under the following conditions.

a. For any item which was used when the rental period began, the item will be considered purchased at the point that a monthly rental payment matches or first approximates the provider's resale value quotation (for that specific piece of equipment) in the original authorization request.

b. For any item which was new when the rental period began, the item will be considered purchased at the point that a monthly rental payment matches or first approximates* 100 percent of the carrier/self-insured employer's maximum allowable purchase price.

*Maximum rental periods for new items are listed in the "Schedule of Maximum Allowances."

3. If a claimant's medical condition changes or does not improve as expected, a rental may be discontinued in favor of a purchase. In such instances, the same policy outlined above will determine the purchase payment amount. The carrier/self-insured employer reserves the right to reevaluate the rental/purchase option at any time within the authorized rental period. Once purchased by the carrier/self-insured employer, any item becomes the property of the claimant.

4. If death or other disqualifying factors intervene, rental fees for equipment will terminate at the end of the month such circumstance(s) occurred and no further payment will be made regardless of the original rental period authorized.

5. The return of the rented equipment is the dual responsibility of the claimant and the provider. The carrier/self-insured employer is not responsible and will not reimburse for additional rental periods solely because of a delay in equipment return.

G. Equipment Warranty Information

1. If a repair authorization is requested, the provider must furnish a copy of the warranty or a statement of warranty denial from the manufacturer. If the warranty period has expired, the filed information must include the date of purchase from the manufacturer and the warranty period allowed.

2. The monthly rental fee allowed for services shall include a full service warranty during the authorized rental period. In addition, routine maintenance, repairs and replacement of rental equipment is the responsibility of the provider.

H. Professional Respiratory Care Services

1. All professional respiratory care services must be:

a. ordered by a physician who specifies the type, frequency, and duration of treatment and, as appropriate, the type and doses of medication, the type of diluent, and the oxygen concentration;

b. consistent with the patient's diagnosis and treatment and assessment of respiratory problems;

c. diagnostic or therapeutic;

d. for acute or chronic respiratory problems; and

e. provided by a physician, registered or certified respiratory therapist, cardiopulmonary technologist or an appropriately trained licensed nurse.

2. Covered professional services include, but are not limited to:

i. ventilation assist and management initiation-this service is not necessarily confined to the critical care area. It can be rendered in a hospital setting or in rare instances the Extended Care Facility (ECF) or home setting. Ventilation assist and management initiation normally includes:

(a). patient's history, physical examinations;

(b). consultation;

(c). continuous positive airway pressure ventilation;

(d). continuous negative pressure ventilation;

(e). establishment of a mechanism necessary for the monitoring of the patient;

(f). evaluation of all laboratory procedures; and

(g). adjustment of treatment plans and maintenance of medical records;

ii. reimbursement for subsequent days of ventilation assist and management is limited to 13 consecutive days unless justification of the medical necessity for additional days is submitted and approved by the carrier/self-insured employer;

b. confirmatory consultation performed by the same physician on the same day as ventilation assist and management is included in the basic allowance of the ventilation assist and management;

c. follow-up consultations performed by the same physician on the same day as follow-up ventilation assist and management are included in the basic allowance of the ventilation assist;

d. pulmonary services performed:

i. by or under the direct supervision of a physician; and

ii. for the diagnosis and/or treatment of pulmonary symptoms or diseases;

e. pulmonary function studies;

f. reimbursement for the following procedures is included in the basic allowance of Spirometry when performed by the same physician on the same day:

i. maximum breathing capacity, maximal voluntary ventilation;

ii. respiratory flow volume loop;

iii. vital capacity, total; and

iv. vital capacity, screening test: total capacity, with timed forced expiratory volume, and peak flow rate;

g. reimbursement for Spirometry is included in the basic allowance of the following studies when performed by the same physician on the same day:

i. bronchospasm evaluation: spirometry before or after bronchodilator (aerosol or parenteral) or exercise; and

ii. prolonged postexposure evaluation of bronchospasm with multiple spirometric determinations after test dose of bronchodilator (aerosol only) or antigen, with spirometry;

h. reimbursement for carbon dioxide, expired gas determination by infrared analyzer, is included in the basic allowance of the specific pulmonary function test performed by the same physician on the same day;

i. pulmonary stress testing, simple or complex, only if a physician is present during the testing. Reimbursement for the following services is included in the basic allowance of pulmonary stress testing:

i. continuous blood pressure monitoring;

ii. expired gas measurements;

iii. maximal or submaximal treadmill or bicycle exercise;

iv. oximetry; and

v. 12 lead electrocardiogram;

i. pulmonary therapy and/or treatment, when performed in the office location:

(a). intermittent positive pressure breathing (IPPB) treatment, air or oxygen, with or without nebulized medication; and

(b). aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes;

(i). reimbursement for medications, supplies and heated aerosol is included in the basic allowance for the treatment;

k. reimbursement for pulmonary therapy and/or treatment is not to exceed five treatments of each type (i.e., IPPB and aerosol) procedure performed within a 30-day period. Reimbursement for pulmonary therapy and/or treatment is allowed in addition to the allowance of an office visit when performed by the same physician on the same day;

i. ventilation assist and management, when performed by the same physician on the same day:

(a). continuous positive airway pressure ventilation (CPAP), initiation and management; and

(b). continuous negative pressure ventilation (CNP), initiation and management;

ii. for ventilation assist and management, rendered in conjunction with Initial Critical Care, see Initial Critical Care. For ventilation assist and management rendered in conjunction with other initial services.

La. Admin. Code tit. 40, § I-4509

Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994).

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.