Oregon Administrative Code

410-122-0210 Ventilators (1) Indications and limitations of coverage: (a) Mechanical ventilatory support may be provided to a client for the purpose of life support during therapeutic support of suboptimal cardiopulmonary function, or therapeutic support of chronic ventilatory fa…

410-122-0211 Cough Stimulating Device (1) Indications and Limitations of Coverage and Medical Appropriateness: The Division may cover a cough stimulating device, alternating positive and negative airway pressure, for a client who meets the following criteria: (a) The client has b…

410-122-0220 Pacemaker Monitor (1) E0610 — Pacemaker monitor, self-contained, checks battery depletion, includes audible and visible check systems: (a) The Division will purchase; (b) Also covered for payment by the Division when client is a resident of a nursing facility. (2) E0…

410-122-0240 Apnea Monitors for Infants (1) Indications and limitations of coverage and medical appropriateness: (a) For infants less than twelve (12) months of age with documented apnea, or who have known risk factors for life-threatening apnea, the Division may cover home apnea…

410-122-0250 Breast Pumps (1) Indications and limitations of coverage and medical appropriateness: (a) In accordance with Prioritized List of Health Services Breastfeeding Support and Supplies Guideline Note, the Division may cover a breast pump and supplies for postpartum women …

410-122-0260 Home Uterine Monitoring (1) Home uterine monitoring (S9001) requires prior authorization (PA) and may be approved for the following conditions: (a) Pre-term labor with one or more of the following complications: (A) Incompetent cervix; (B) Cervical cerclage; (C) Poly…

410-122-0280 Heating/Cooling Accessories Procedure Codes for Heating/Cooling Accessories: Table 122-0280. [ED. NOTE: Tables referenced are available from the agency.] [ED. NOTE: To view attachments referenced in rule text, click here for PDF copy.] Statutory/Other Authority: ORS …

410-122-0300 Light Therapy (1) Indications and limitations of coverage and medical appropriateness: The Division may cover home phototherapy when medically appropriate and for the following conditions: (a) For a term or near-term infant whose elevated bilirubin is not due to a pr…

410-122-0320 Manual Wheelchair Base (1) Indications and limitations of coverage and medical appropriateness: (a) The Division may cover a manual wheelchair when conditions of coverage in OAR 410-122-0080 and all of the following criteria are met: (A) The client has a mobility lim…

410-122-0325 Power Wheelchair Base (1) Indications and limitations of coverage and medical appropriateness: (a) The Division may cover a power wheelchair (PWC) when conditions of coverage in OAR 410-122-0080 and all the following criteria are met: (A) The client has a mobility li…

410-122-0330 Power-Operated Vehicle (1) Indications and limitations of coverage and medical appropriateness: (a) The Division may cover a power-operated vehicle (POV) when conditions of coverage in OAR 410-122-0080 and all of the following criteria are met: (A) The client has a m…

410-122-0340 Wheelchair Options/Accessories (1) Indications and limitations of coverage and medical appropriateness: (a) The Division may cover options and accessories for covered wheelchairs when the following criteria are met: (A) The client has a wheelchair that meets Division…

410-122-0360 Canes and Crutches (1) Indications and Coverage: When prescribed by a practitioner for a client with a condition causing impaired ambulation and there is a potential for ambulation. (2) A white cane for a visually impaired client is considered to be a self-help item …

410-122-0365 Standing and Positioning Aids (1) Indications and limitations of coverage and medical appropriateness: Standing frame systems, prone standers, supine standers or boards, and accessories may be covered by the Division when conditions of coverage in OAR 410-122-0080 an…

410-122-0375 Walkers (1) Indications and Limitations of Coverage: (a) A standard walker (E0130, E0135, E0141, E0143) and related accessories are covered if both of the following criteria are met: (A) When prescribed by a treating practitioner for a client with a medical condition…

410-122-0380 Hospital Beds (1) Indications and limitations of coverage and medical appropriateness: The Division may cover a hospital bed when conditions of coverage in OAR 410-122-0080 and the following criteria are met: (a) A fixed height hospital bed (E0250, E0251, E0290, E029…

410-122-0400 Pressure Reducing Support Surfaces (1) Indications and limitations of coverage and medical appropriateness: (a) Group 1 (A4640, E0181–E0182, E0184–E0189, and E0196-E0199): (A) The Division may cover a Group 1 support surface when the client meets: (i) Criterion (I), …

410-122-0420 Hospital Bed Accessories (1) Table 122-0420, Hospital Bed Accessories Procedure codes — Trapeze Bars: (a) Indications and coverage: Trapeze bars are indicated when a client needs this device to sit up because of respiratory condition, to change body position for othe…

410-122-0475 Therapeutic Shoes for Diabetics (1) Indications and Coverage: (a) For each client, coverage of the footwear and inserts is limited to one of the following within one calendar year: (A) One pair of custom-molded shoes (including inserts provided with such shoes) and t…

410-122-0510 Osteogenesis Stimulator (1) Definitions: (a) An electrical osteogenesis stimulator is a device that provides electrical stimulation to augment bone repair; (b) A noninvasive electrical stimulator is characterized by an external power source that is attached to a coil…

410-122-0515 Neuromuscular Electrical Stimulator (NMES) Indications and limitations of coverage and medical appropriateness: The Division may cover a neuromuscular electrical stimulator (NMES) that uses electrodes to transmit an electrical impulse to the skin over selected muscle…

410-122-0520 Glucose Monitors and Diabetic Supplies (1) Indications and limitations of coverage and medical appropriateness: (a) The Division may cover home blood glucose monitors and related diabetic supplies for clients with diabetes who can self-monitor blood glucose (SMBG) or…

410-122-0525 External Insulin Infusion Pump (1) Indications and limitations of coverage and medical appropriateness: (a) The Division may cover an external insulin infusion pump for the administration of continuous subcutaneous insulin for the treatment of diabetes mellitus when …

410-122-0540 Ostomy Supplies (1) Indications and Limitations of Coverage and Medical Appropriateness: The Division may cover ostomy supplies for a client with a surgically created opening (stoma) to divert urine or fecal contents outside the body: (a) Only one liquid barrier may …

410-122-0560 Urological and Bowel Supplies (1) Indications and Limitations of Coverage and Medical Appropriateness: (a) The Division may cover the following urinary catheters, external urinary collection devices, and medically appropriate related supplies when used to drain or co…

410-122-0580 Bath Supplies (1) Indications and limitations of coverage and medical appropriateness: The Division may cover bath supplies when the client meets the conditions of coverage in OAR 410-122-0080 and when the following guidelines are met: (a) A rehab shower/commode chai…

410-122-0590 Patient Lifts (1) Indications and coverage — A lift is covered if transfer between bed and a chair, wheelchair, or commode requires the assistance of more than one person and, without the use of a lift, the client would be bed confined. (2) The areas within the clien…

410-122-0600 Toilet Supplies (1) The Division may consider coverage for commodes when: (a) The client is physically incapable of utilizing regular toilet facilities. This would occur when the client is confined to: (A) A single room; or (B) One level of the home environment and t…

410-122-0620 Miscellaneous Supplies Procedure Codes — Table 122-0620. [ED. NOTE: To view attachments referenced in rule text, click here for PDF copy.] Statutory/Other Authority: ORS 413.042 & 414.065 Statutes/Other Implemented: ORS 414.065 History: DMAP 87-2025, amend filed 12/0…

410-122-0625 Surgical Dressing Procedure Codes: Table 122-0625 Surgical Dressing. [ED. NOTE: Tables referenced are available from the agency.] [ED. NOTE: To view attachments referenced in rule text, click here for PDF copy.] Statutory/Other Authority: ORS 413.042 & 414.065 Statut…

410-122-0630 Incontinent Supplies (1) The Division may cover incontinent supplies for urinary or fecal incontinence in accordance with Prioritized List of Health Services Fecal Incontinence Guideline Note and as follows: (a) Category I Incontinent Supplies: For up to 200 units (a…

410-122-0640 Eye Prostheses (1) Indications and coverage: (a) An eye prosthesis is indicated for a client (adult or child) with absence or shrinkage of an eye due to birth defect, trauma, or surgical removal; (b) For clients under age 21, the prescribing practitioner shall determ…

410-122-0655 External Breast Prostheses (1) Indications and Limitations of Coverage and Medical Appropriateness: (a) The Division may cover an external breast prosthesis for a client who has had a mastectomy; (b) An external breast prosthesis garment, with mastectomy form (L8015)…

410-122-0658 Gradient Compression Stockings/Sleeves (1) Indications and Limitations of Coverage and Medical Appropriateness: (a) The Division may cover gradient compression stockings/sleeves for the following indications when the client meets the conditions of coverage in OAR 410…

410-122-0660 Orthotics and Prosthetics (1) Indications and limitations of coverage and medical appropriateness: (a) The Division may cover some orthotics and prosthetics for covered conditions; (b) Use the current Healthcare Common Procedure Coding System (HCPCS) Level II Guide f…

410-122-0662 Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses (1) Indications and limitations of coverage and medical appropriateness: The Division may cover some ankle-foot orthotics (AFOs) and knee-ankle-foot Orthotics (KAFOs) and related services for a covered condition, for t…

410-122-0678 Dynamic Adjustable Extension/Flexion Device (1) Indications and limitations of coverage and medical appropriateness: The Division may cover some dynamic adjustable extension/flexion devices for a covered condition when all of the following conditions are met: (a) As …

410-122-0680 Facial Prostheses (1) Indications and Coverage: (a) Covered when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect; (b) Adhesives, adhesive remover and tape used in conjunction with a facial prosthesis are covered. Othe…

410-122-0700 Negative Pressure Wound Therapy Pumps (1) Indications and limitations of coverage and medical appropriateness — Initial Coverage: The Division may cover a negative pressure wound therapy (NPWT) pump and supplies on a monthly basis for up to four months on the most re…

410-122-0710 Adaptive Car Seats and Travel Vests (1) Indications and limitations of coverage and medical appropriateness: Adaptive car seats and travel vests provide safety during transportation in a vehicle for individuals of all ages with health care needs that cannot be met us…

410-122-0720 Pediatric Wheelchairs (1) Indications and limitations of coverage and medical appropriateness: (a) For clients under the age of 21: The EPSDT program covers all medically necessary and medically appropriate services needed to correct or ameliorate health conditions, …

410-122-0730 Continuous Glucose Monitoring Equipment and Supplies (1) Indications and Limitations of Coverage and Medical Appropriateness: (a) The Division shall cover personal, real-time continuous glucose monitoring (CGM) equipment and supplies for clients with a diagnosis of t…

410-123-1060 Definitions and Acronyms The acronyms and definitions within this rule specifically pertain to dental services. This rule does not include an exhaustive list of acronyms and definitions that apply to dental services. All Authority rules are intended to be used in con…

410-123-1160 Prior Authorization (1) The Authority covers the following services only with Prior Authorization (PA) approval: (a) Crowns: (A) Porcelain fused to metal (D2751, D2752); and (B) Porcelain ceramic (D2740); (b) Crown repair necessitated by restorative material failure …

410-123-1250 HbA1c Testing (1) The Authority covers Hemoglobin A1c (HbA1c) testing for at risk members per scope of practice for Oregon licensed oral health providers. (2) Although not presumed to be a standard of care, testing serves as a resource for licensed oral health provid…

410-123-1260 Coverage, Limitations, Exclusions (1) The Oregon Health Authority (Authority) offers Medicaid dental/denturist benefits on a Fee-For-Service (FFS) basis: (a) Providers must be licensed to practice dentistry and enrolled as a Medicaid provider as required by OAR 410-1…

410-123-1262 Vaccine Counseling and Administration (1) Dental administration of vaccines must be carried out in compliance with Oregon Board of Dentistry OARs 818-012-0006 and 818-012-0007, OHA Medical/Surgical OAR 410-130-0255 and Vaccines for Children (VFC) – OHA Division 46, O…

410-123-1265 Teledentistry (1) Teledentistry can take multiple forms, both synchronous and asynchronous, including but not limited to: (a) Live video, a two-way interaction between a member and dentist using audiovisual technology; (b) Store and forward, an asynchronous transmiss…

410-123-1490 Hospital Dentistry (1) The purpose of hospital dentistry is to provide safe, efficient dental care when providing routine (non-emergency) dental services for members who present special challenges that require the use of general anesthesia or intravenous (IV) conscio…

410-123-1510 Additional Dental Benefits for Pregnant and Postpartum Members (1) This rule sets forth the access standards for dental care for members who are pregnant or 12 months postpartum. (2) Pregnant members must be seen, treated in person or via teledentistry for the follow…