Section 182-552-1000. Respiratory care—Covered—Respiratory and ventilator equipment and supplies.

(1) The medicaid agency covers the rental of a ventilator, equipment, and related disposable supplies when the ventilator is for the treatment of chronic respiratory failure (chronic carbon dioxide retention).

(2) The medicaid agency's monthly rental rate includes ventilator maintenance and accessories including, but not limited to, humidifiers, nebulizers, alarms, temperature probes, batteries, chargers, adapters, connectors, fittings, tubing, disposable circuits, and filters. The medicaid agency does not pay separately for ventilator accessories unless the client owns the ventilator system, see subsection (5) of this section.

(3) Ventilators, equipment, and related disposable supplies must:

(a) Be used exclusively by the client for whom it is requested;

(b) Be FDA-approved; and

(c) Not be included in any other reimbursement methodology such as, but not limited to, a diagnosis-related group (DRG).

(4) The medicaid agency pays for a back-up (secondary) ventilator at fifty percent of the monthly rental rate when one or more of the following clinical criteria are met:

(a) The client cannot maintain spontaneous ventilations for four or more consecutive hours;

(b) The client lives in an area where a replacement ventilator cannot be provided within two hours;

(c) The client requires mechanical ventilation during mobility as prescribed in their plan of care.

(5) The medicaid agency pays for the purchase of the following replacement ventilator accessories only for client-owned ventilator systems:

(a) Gel-cell battery charger - One every twenty-four months;

(b) Gel-cel heavy-duty battery - One every twenty-four months;

(c) Battery cables - Once every twenty-four months; and

(d) Breathing circuits - Four every thirty days.

(6) Pressure support ventilators.

(a) For clients eighteen years of age and older, the medicaid agency requires prior authorization;

(b) For clients seventeen years of age and younger, the medicaid agency requires expedited prior authorization (EPA).

(i) The following criteria must be met in order to use the EPA process:

(A) The client is currently using a pressure support ventilator;

(B) The client must be able to take spontaneous breaths;

(C) There must be an authorized prescriber's order for the pressure support setting; and

(D) The client must be utilizing the ventilator in the pressure support mode.

(ii) If the client has no clinical potential for weaning, the medicaid agency's EPA is valid for twelve months; or

(iii) If the client has the potential to be weaned, then the medicaid agency's EPA is valid for six months;

(iv) To continue using EPA after the valid time period has lapsed, a vendor must document in the client's file that the client continues to meet the EPA criteria for a pressure support ventilator.

[Statutory Authority: RCW 41.05.021. WSR 12-14-022, § 182-552-1000, filed 6/25/12, effective 8/1/12.]

RCW 41.05.021. WSR 12-14-022, § 182-552-1000, filed 6/25/12, effective 8/1/12.