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Information for prescribers - DME
& Oxygen
Page Links - Oxygen
CPAP / BiPAP
Wheelchairs Walkers
Hospital Beds
Nebulizers
Scooters
Diabetic Shoes
 OXYGEN
information
The following is qualifying information for Medicare and most
insurance company coverage. Click on the picture to the
right to download a page with Oxygen qualifying information.
1. An arterial PO2 at or below 55 mmHg or an arterial oxygen
saturation at or
below 88 percent taken at rest (awake), or
2. An arterial PO2 at or below 55 mmHg, or an arterial oxygen
saturation at or below 88 percent, taken during sleep for a
patient who demonstrates an arterial PO2 at or above 56 mmHg or
an arterial oxygen saturation at or above 89% while awake, or
3. A decrease in arterial PO2 more than 10 mmHg, or a decrease
in arterial oxygen saturation more than 5 percent taken during
sleep associated with symptoms or signs reasonably attributable
to hypoxemia (e.g., corpulmonale, “P” pulmonale on EKG,
documented pulmonary hypertension and erythrocytosis), or
4. An arterial PO2 at or below 55 mmHg or an arterial oxygen
saturation at or below 88 percent, taken during exercise for a
patient who demonstrates an arterial PO2 at or above 56 mmHg or
an arterial oxygen saturation at or above 89 percent during the
day while at rest. In this case, oxygen is provided during
exercise if it is documented that the use of oxygen improves the
hypoxemia that was demonstrated during exercise when the patient
was breathing room air.
5. Dependent edema suggesting congestive heart failure, or
6. Pulmonary hypertension or cor pulmonale, determined by
measurement of pulmonary artery pressure, gated blood pool scan,
echocardiogram, or “P” pulmonale on EKG (P wave greater than 3
mm in standard leads II, III, or AVF), or
7. Erythrocythemia with a hematocrit greater than 56 percent.
If one or more of the coverage conditions specified above are
not met, the oxygen therapy will be considered not medically
necessary. Oxygen therapy will also be considered not medically
necessary if any of the following conditions are present:
a. Angina pectoris in the absence of hypoxemia. This condition
is generally not the result of low oxygen level in the blood and
there are other preferred treatments.
b. Dyspnea without cor pulmonale or evidence of hypoxemia.
c. Severe peripheral vascular disease resulting in clinically
evident desaturation in one or more extremities but in the
absence of systemic hypoxemia. There is not sufficient medical
evidence that increased PO2 will improve the oxygenation of
tissues with impaired circulation.
d. Terminal illnesses that do not affect the respiratory system.
The qualifying blood gas study must be performed by a physician,
qualified Medicaid provider or qualified laboratory. The
qualifying blood gas study may be performed while the patient is
on oxygen as long as the reported blood gas values meet the
coverage criteria.
Overnight oximetry testing:
<CLICK HERE>
to download an order for overnight oximetry
testing. Testing information is uploaded to IDS (Instant
Diagnostic Systems) and that information can be used to qualify
a patient for insurance coverage of their oxygen therapy
equipment.
Note: Maier Family Pharmacy has 24/7 Oxygen service.
Setups can be done the same day as O2 is ordered and all setups
include patient training and follow-ups by our RT. Maier
Family Pharmacy is franchised with ConvaCare Services, a
subdivision of Lincare, for our Oxygen services. This
enables us to have nation-wide Oxygen coverage for patients who
travel or vacation in other parts of the country. Patient
care is provided by the Home Healthcare staff of Maier Family
Pharmacy and physicians are notified if patient compliance isn't
being met.
CPAP / BiPAP
information
How is obstructive sleep apnea diagnosed?
OSA must be diagnosed by an attended, facility based
polysomnogram, and the patient must meet one of the following
Apnea-Hypopnea Index (AHI) criteria:
1. AHI >– 15 events per hour
2. AHI from 5 to 14 events per hour with documented symptoms of:
A) excessive daytime sleepiness, impaired cognition, mood
disorders or insomnia; or B) documented hypertension, ischemic
heart disease or history of stroke.
What is Medicare’s definition of AHI?
 The
AHI is defined as the average number of episodes of apnea and
hypopnea per hour, and must be based on a minimum of two hours
of recording time without the use of a positive airway pressure
device, reported by polysomnogram.
Apnea is defined as the cessation of airflow for at least 10
seconds as documented on a polysomnogram. Hypopnea is defined as
an abnormal respiratory event lasting at least 10 seconds and
associated with at least a 30% reduction in thoracoabdominal
movement or airflow as compared to baseline, and with at least a
4% decrease in oxygen saturation.
CPAP and BiPAP systems and supplies can only be dispensed
with a prescription. Maier Family Pharmacy requires
a copy of the patient's split sleep study for all new CPAP orders.
The sleep study is also needed for ongoing billing of patient
supplies like masks, tubing and filters. CPAP
prescriptions are generally written by the patient's physician
after a recommendation from a certified sleep lab therapist or
technician. If a
patient is requiring a new mask, tubing or filters, please write
a prescription for Mask and supplies.
Please
fax all sleep study information along with a prescription to:
712-881-1206.
Note: In most cases, CPAP setups require 2-4 days to order
the correct mask for the patient. The patient will be
contacted for a setup time and date from our respiratory
therapist.
Maier Family Pharmacy does not perform sleep studies.
Physicians or patients can order sleep studies through the area
hospital sleep labs or by an independent firm.
Qualifying information must include the AHI#
WHEELCHAIR
information
 Wheelchairs
require a CMN form for billing purposes.
Click Here
to download a wheelchair CMN form.
The CMN requires a prescriber to enter diagnosis codes, not a
narrative diagnosis.
1. When writing a prescription for a wheelchair, indicate the
patient's weight and height. If the patient has a larger
than average hip measurement, include this on the prescription.
2. Include a diagnosis (need) for the wheelchair.
3. Indicate the length of time the patient will need the
equipment.
After we receive a prescription (not a CMN) for a wheelchair, a
CMN form will be sent to the prescriber to fill out.
WALKER
information
 When
writing a prescription for a walker, indicate the type of walker
the patient needs. If the patient requires a rolling
walker (like the picture to the right), write a prescription for
a rolling walker with seat and brakes. If the patient
requires a standard folding walker, write the prescription for a
standard walker.
Note: Patients with very limited hand strength may have a hard
time operating the brakes on a rollator.
Include the patient's diagnosis, length of need, height
and weight on the prescription.
Maier Family Pharmacy stocks standard folding walkers, deluxe
and standard Medline Rollators and jr.-sized walkers for
children or short adults. Patients can also find
accessories like trays, bags, wheels and replacement tips at the
pharmacy.
HOSPITAL BED
information
 Maier
Family Pharmacy stocks standard semi-electric Medline hospital
beds. Head and foot elevations are controlled by the
patient with a remote control. The overall height of the
bed is adjustable with a crank on the end of the bed. All
beds come with a standard twin size mattress w/cover and bed
rails. Beds are usually delivered the same day as the
prescription is received unless otherwise specified by the
patient or patient's family.
When writing a prescription for a hospital bed include the
following:
1. Patient's height and weight
2. Diagnosis
3. Length of need
Prescribers can also download
Hospital Bed CMN
form to fill out in place of a prescription. After
receiving a prescription, a CMN form will be sent to the
prescriber.
NEBULIZER information
Nebulizer compressors and nebulizer breathing kits require a
prescription. Maier Family Pharmacy requires a separate
prescription from the nebulizer solution to dispense a
compressor or neb. kit. When writing a prescription for a
nebulizer include the following information:
1. Patient's name
2. Diagnosis
3. Length of need. (If the patient has COPD and/or require
multiple rentals or treatments, use 99 for length of need to
help insure a purchase or extended rental period from insurance
company).
Note: Patients can purchase a nebulizer if they have a valid
prescription. Replacement neb kits also require a
prescription.
DIABETIC SHOES
information
 Diabetic
shoes are covered by Medicare and some insurance policies.
With Medicare and a supplement plan, there is little-to-no cost
for the patient. Diabetic shoes require a physician's
order to be covered by Medicare. Click Here to download an
order form and brochure that explains the benefits of Diabetic
footwear.
Maier Family Pharmacy carries Dr.
Comfort and
Orthofeet
diabetic shoes. (Click on the brand name to see a
selection of the shoes carried by MFP) Insoles for the
diabetic shoes can be either heat-moldable or custom-made from a
mold of the patient's foot.
 Custom-insoles
are made at either the Ped-Lite lab in Indiana, or the Dr.
Comfort lab in Wisconsin.. MFP has the patient step into a box
containing a soft biofoam. This impression is used to
create a cast mold of the patient's foot by which the orthotic
is created at the lab.
Diabetic shoes can also be privately purchased without a
prescription for patients who suffer from foot problems.
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In an effort to save time, we ask that prescribers include the
following information on their prescriptions when writing an
order for medical equipment.
-
TYPE OF EQUIPMENT BEING PRESCRIBED
-
DIAGNOSIS OR DIAGNOSIS CODE
-
LENGTH OF NEED
-
PATIENT WEIGHT & HEIGHT IF NON-STANDARD EQUIPMENT BEING
ORDERED*
* If a patient's weight is over 250lbs., please include
height & weight on prescription.
By
including this information on the prescription, additional
paperwork can be avoided.
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411
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