Or. Admin. Code § 410-122-0365

Current through Register Vol. 63, No. 12, December 1, 2024

Section 410-122-0365 - Standing and Positioning Aids

(1) Indications and coverage: Standing frame systems, prone standers, supine standers or boards, and accessories are covered when:

(a) The client is unable to stand or ambulate independently due to conditions such as, but not limited to, neuromuscular or congenital disorders, including acquired skeletal abnormalities;

(b) The client is at high risk for lower extremity contractures that cannot be appropriately managed by other treatment modalities (i.e., stretching, active therapy, home programs, etc)

(c) The client has been sequentially evaluated by a physical or occupational therapist to make certain the client can tolerate a standing or upright position and obtain medical benefit; and,

(d) The client is following a home therapy program for the stander established by a physical or occupational therapist; and

(e) The home is able to accommodate the equipment; and

(f) The weight of the client does not exceed manufacturer's weight capacity; and

(g) The client has demonstrated an ability to utilize the standing aid independently or with assistance from a caregiver; and

(h) The client has demonstrated compliance with other programs; and

(i) The client has demonstrated a successful trial period in a monitored setting; and

(j) The client does not have access to equipment from another source.

(2) Sidelyers and custom positioners shall meet the following criteria in addition to the criteria in Table 122-0365:

(a) The client shall be sequentially evaluated by a physical or occupational therapist to make certain the client can tolerate and obtain medical benefit; and

(b) The client shall be following a therapy program initially established by a physical or occupational therapist; and,

(c) The home shall be able to accommodate the equipment; and

(d) The caregiver or family are capable of using the equipment appropriately.

(3) Criteria for Specific Accessories:

(a) A back support may be covered when a client:

(A) Needs balance, stability, or positioning assistance; or

(B) Has extensor tone of the trunk muscles; or

(C) Needs support while being raised or while completely standing;

(b) A tall back may be covered when:

(A) The client is over 5'11" tall; and

(B) The client has no trunk control and needs additional support; or

(C) The client has more involved need for assistance with balance, stability, or positioning;

(c) Hip guides may be covered when a client:

(A) Lacks motor control or strength to center hips; or

(B) Has asymmetrical tone that causes hips to pull to one side; or

(C) Has spasticity; or

(D) Has low tone or high tone; or

(E) Needs balance, stability, or positioning assistance;

(d) A shoulder retractor or harness may be covered when:

(A) Erect posture cannot be maintained without support due to lack of motor control or strength; or

(B) Has kyphosis; or

(C) Presents strong flexor tone;

(e) Lateral supports may be covered when a client:

(A) Lacks trunk control to maintain lateral stability; or

(B) Has scoliosis that requires support; or

(C) Needs a guide to find midline;

(f) A headrest may be covered when a client:

(A) Lacks head control and cannot hold head up without support; or

(B) Has strong extensor thrust pattern that requires inhibition;

(g) Independent adjustable knee pads may be covered when a client:

(A) Has severe leg length discrepancy; or

(B) Has contractures in one leg greater than the other;

(h) An actuator handle extension may be covered when a client:

(A) Has no caregiver; and

(B) Is able to transfer independently into standing frame; and

(C) Has limited range of motion in arm or shoulder and cannot reach actuator in some positions;

(i) Arm troughs may be covered when a client:

(A) Has increased tone that pulls arms backward so hands cannot come to midline; or

(B) Has poor tone, strength, or control that causes arms to hang out to side and backward causing pain and risking injury; or

(C) Has needs for posture;

(j) A tray may be covered when proper positioning cannot be accomplished with other accessories;

(k) Abductors may be covered to reduce tone for proper alignment and weight bearing;

(l) Sandals (shoe holders) may be covered when a client:

(A) Has dorsiflexion of the foot or feet; or

(B) Has planar flexion of the foot or feet; or

(C) Has eversion of the foot or feet; or

(D) Has need for safety.

(4) If a client has one aid that meets medical needs, regardless of who obtained it, the Division may not provide another aid of same or similar function.

(5) Gait Belts (E0700) shall be covered when:

(a) The client weighs 60 lbs. or more; and

(b) The care provider is trained in the proper use; and

(c) The client can walk independently but needs:

(A) A minor correction of ambulation; or

(B) Minimal or standby assistance to walk alone; or

(C) Requires assistance with transfer;

(6) Documentation that shall be kept on file by the Durable Medical Equipment (DME) provider includes:

(a) Documentation of medical appropriateness, which has been reviewed and signed by the prescribing practitioner;

(b) The care plan outlining positioning and treatment regimen and all DME currently available for use by the client;

(c) The practitioner's order;

(d) Each item requested shall be itemized with description of product, make, model number, and manufacturers' suggested retail price (MSRP);

(e) The Positioner Justification form (DMAP 3155) or reasonable facsimile with recommendation for most appropriate equipment completed by the prescribing practitioner or the evaluating PT or OT;

(7) Providers shall use the appropriate HCPCS code assigned to the standing system base (e.g., E0637, E0638, E0641, and E0642).

(8) Providers shall use E1399 for standing frame accessories when billing separately from the base. PDAC coding verification is not required on standing frame equipment and accessories as this is statutorily excluded from Medicare coverage and as such does not have an assigned HCPCS code.

(9) Table 122-0365.

Or. Admin. Code § 410-122-0365

OMAP 37-2000, f. 9-29-00, cert. ef. 10-1-00; OMAP 32-2001, f. 9-24-01, cert. ef. 10-1-01; OMAP 47-2002, f. & cert. ef. 10-1-02; OMAP 21-2003, f. 3-26-03, cert. ef. 4-1-03; OMAP 25-2004, f. & cert. ef. 4-1-04; OMAP 44-2004, f. & cert. ef. 7-1-04; OMAP 94-2004, f. 12-30-04, cert. ef. 1-1-05; OMAP 47-2006, f. 12-15-06, cert. ef. 1-1-07; DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 37-2008, f. 12-11-08, cert. ef. 1-1-09; DMAP 11-2016, f. 2-24-16, cert. ef. 3/1/2016; DMAP 101-2023, amend filed 12/29/2023, effective 1/1/2024; DMAP 12-2024, minor correction filed 01/04/2024, effective 1/4/2024

Tables referenced are available from the agency.

To view attachments referenced in rule text, click here to view rule.

Statutory/Other Authority: ORS 413.042 & 414.065

Statutes/Other Implemented: ORS 414.065