Sec. 10.09.18.05. Limitations

A. The Program does not cover:

(1) Any service or items not identified in Regulation .04 of this chapter;

(2) Demurrage;

(3) Charges for delivery;

(4) Equipment prescribed primarily to provide comfort or convenience, including, but not limited to, air conditioners and room humidifiers;

(5) Items which are investigational or experimental in nature;

(6) Oxygen and related equipment not for pulmonary use;

(7) Pre-set oxygen for emergency use;

(8) Trach string or tape.

B. The Program places the following limitations upon covered services:

(1) Reimbursement for aerosol equipment will only be provided if a hand held nebulizer has been tried and is not successful, as indicated in the clinical summary;

(2) Reimbursement for IPPB machine will only be authorized if the aerosol compressor with the nebulizer kit has been tried and is not successful, as indicated in the clinical summary;

(3) Reimbursement may not be made for:

(a) Repairs or replacement parts for rented items;

(b) Oxygen prescribed on an as-needed basis (PRN);

(c) Oxygen prescribed for stand-by purposes;

(d) Piped-in oxygen;

(e) Oxygen and related respiratory equipment and services provided in a facility or by a group when reimbursement is covered by another segment of the Program; and

(4) Payment for portable oxygen will be made only when:

(a) It is required in the pursuit of medical treatment; and

(b) The medical necessity is indicated for this type of system.