PROVIDER POLICIES & PROCEDURES

Transcription

1 PROVIDER POLICIES & PROCEDURES PATIENT LIFT SYSTEMS The primary purpose of this document is to assist providers enrolled in the Connecticut Medical Assistance Program (CMAP) with the information needed to support a medical necessity determination for patient lift systems. By clarif ying t he inf ormat ion needed f or prior aut horizat ion of services, HUSKY Health hopes to facilitate timely review of requests so t hat individuals obt ain the medically necessary care they need as quickly as possible. A patient lift is used to safely transfer an individual with physical limitations between bed, chair, wheelchair, commode, or shower/ bath chair and back, using electric, mechanical, or hydraulic power. Types of lift syst ems include a mobile floor lift, a sit -to-st and lift, a fixed overhead lift suspended from a ceiling mount or overhead track, and a port able lift suspended from overhead or wall t rack in which t he mot or is det aching and reat t ached between the various tracks. Patient lifts, incorporate a postural component for the person being lifted; i.e., straps, vests, slings, belts, body cradle. A patient lift with a sling and/ or or other seated postural component is generally used for persons whose mobility is limited, who is unable t o t ransfer independent ly using ot her durable medical equipment, t ransfer st rat egies, or assist ance from a caret aker. A sit-to-st and lift is used for persons wit h some mobility but who lack st rengt h or muscle cont rol t o rise t o a st anding posit ion from a bed, wheeled mobility device, chair, or commode. These lifts use straps, vests, or belts to make this transition possible. CLINICAL GUIDELINE Coverage guidelines for patient lift systems are made in accordance wit h t he Depart ment of Social Services (DSS) definit ion of Medical Necessit y. The following crit eria are guidelines only. Coverage determinations are based on an assessment of the individual and his or her unique clinical needs. If the guidelines conflict with the definition of Medical Necessity, the definition of Medical Necessity shall prevail. The guidelines are as follows: A patient lift may be medically necessary when the individual is unable t o t ransfer with the assist ance of one person, including being unable to use an assistive device or utilize nonmechanical methods. The specific type of lift requires a comprehensive analysis of the person s physical capacities and limitations, current transfer methods, safety issues, caretaker support, and environmental factors. 1

2 Hydraulic or mechanical patient lifts are t ypically considered medically necessary or individuals with physical disabilities who meet the following criteria: 1. When t ransfers cannot be performed independent ly and require t he assist ance of more than one person and when t he individual cannot be safely transferred without a mechanical lift due to the person s medical condition or caretaker limitations; and 2. When the individual would be bed confined without the use of a lift ; and 3. When t here is evidence t hat t he equipment fit s in areas/ rooms where it will be used. Ot her t ypes of pat ient lift s are t ypically considered medically necessary for individuals with physical disabilities when: 1. The above criteria are met; and 2. A hydraulic mechanical lift is proven ineffect ive for t he individual s safet y and medical condition; and 3. Other transfer methods have been demonstrated to be unsafe or not possible. Request s f or pat ient lift s not m eet ing t he abov e crit eria m ay be considered m edically necessary based on an assessment of the individual and his or her unique clinical needs. The following it ems typically do not meet the definition of durable medical equipment since they are not primarily medical in nat ure. However, t hese it ems may be considered medically necessary based on an assessment of t he individual and his or her unique clinical needs 1. Van or car lift s (used t o lift wheelchair int o a vehicle). 2. Wheelchair lift s, plat form lift s, porch lift s, elevat ors, or ramps addressing accessibilit y barriers. 3. Home modifications associated with installation of a lift or access within a home. Repairs, adjustments, or replacement of parts and accessories necessary for the normal and effective functioning of the patient lift equipment are t ypically covered when the above criteria are met. Repairs, adjust m ent s and replacem ent of part s and accessories not meeting the above criteria may be considered medically necessary based on an assessment of the individual and his or her unique needs. NOTE: EPSDT Special Provision: Early and Periodic Screening, Diagnosis, and Treat ment (EPSDT) is a federal Medicaid requirement that requires the Connecticut Medical Assistance Program (CMAP) to cover services, products, or procedures for Medicaid enrollees under 21 years of age where the service or good is medically necessary healt h care t o correct or ameliorat e a defect, physical or ment al illness, or a condit ion ident ified t hrough a screening examinat ion. The applicable definit ion of medical necessit y is set 2

3 forth in Conn. Gen. Stat. Section 17b-259b (2011) [ref. CMAP Provider Bulletin PB ]. PROCEDURE Prior aut horizat ion of patient lifts is required. Request s for coverage will be reviewed in accordance wit h procedures in place for reviewing request s for durable medical equipment. Coverage determinations will be based upon a review of requested and/ or submitted case-specific informat ion. Hydraulic/ Mechanical and Elect ric Pat ient Lif t s (E0630, E0635) Init ial Authorization Re que st s A hydraulic or mechanical patient lift and an electric patient lift are generally rented before a purchase and require a prior authorization. These lifts are usually rented for 1 to 3 months. The following informat ion is needed t o review request s for the rental of a hydraulic or mechanical patient lift or an electric patient lift: 1. Fully completed Out pat ient Prior Authorization Request Form or fully completed aut horizat ion request via on-line web portal; 2. A prescription written within the past three (3) months from a licensed physician (MD or DO), Advanced Pract ice Regist ered Nurse ( APRN), or Physician s Assistant (PA) enrolled in t he Connect icut Medical Assist ance Program (CMAP); 3. A signed let t er of medical necessit y describing t he individual s medical condition as it relates to the need for a specific patient lift system. The informat ion should t ypically include: a. individual s height and weight ; b. medical evaluation by the individual s physician, which may be eit her a specific evaluat ion for a patient lift, signed discharge orders from a hospit al or nursing facility, or other evaluat ion, such as t he most recent hist ory and physical examinat ion and subsequent progress not es; c. ant icipat ed lengt h of t ime t hat t he individual will need a patient lift ; and d. List of all current durable medical equipment ; i.e., wheeled mobilit y device, st ander, walker, hygiene equipment, orthotics, and prosthetics; including manufacturer, model number (when available), and special feat ures; dat e of purchase, and individuals abilit y t o independent ly ut ilize. Re - authorization Re que st s Reaut horizat ion bey ond t he init ial rent al period is required. The rent al period of a hydraulic or mechanical patient lift and an electric patient lift are used t o evaluat e t he effect iveness of t he specific 3

4 patient lift for the individual. This informat ion obt ained during t he rent al period is used t o determine if a patient lift is needed beyond the rental period, if the type of lift used during the rental period is appropriate, or if a different type of patient lift is needed. The following informat ion is needed t o review request s for t he reaut horizat ion of a hydraulic, mechanical or electric patient lift: 1. Fully completed Out pat ient Prior Authorization Request Form or fully completed aut horizat ion request via on-line web portal; including updat ed documents used for the initial authorization request if t he individual s medical condition and anticipated lengt h of need has changed; 2. Document at ion describing a home evaluat ion wit h recommendat ions from a Connect icut licensed occupat ional t herapist, physical t herapist, or regist ered nurse, performed within three (3) months prior to submission of the prior authorization request, which meets the criteria in the above Clinical Guideline. The clinical documentation should include t he following: a. Individual s medical condition and functional status that requires the specific kind of lift requested; b. Descript ion of t his person s ambulat ion, mobilit y, and t ransfer met hod(s), including independence, safet y, amount and t ype of assist ance from ot hers, and reason this method does not meet the recipient s needs; such as postural/ motor control, muscle strength, tone, coordination/ balance, range of motion, cardiopulmonary status; c. Individual s weight and height, and general strength/ health and age of primary caretaker; d. Descript ion of t ype and amount of caret aker support ; e. Ot her f unct ional st rat egies or DME evaluat ed or considered and reason f or ineffect iveness; f. List of all current durable medical equipment ; i.e., wheeled mobilit y device, st ander, walker, hygiene equipment, ort hot ics, and prost het ics; including manufacturer, model, and special features; date of purchase, and individual s abilit y t o independent ly ut ilize; g. Document ed evidence that the request ed pat ient lift addresses the individual s current medical condition and associated functional needs, plans for ant icipat ed medical change; and h. If the provider is requesting authorization for an electric lift aft er rent al of a hydraulic or mechanical lift, documentation regarding why the hydraulic or mechanical lift did not meet the individual s needs. In t hese instances the elect ric lift is typically rented prior to purchase. 3. A detailed product description including manufact urer, model/ part number, product description, HCPC code, unit(s), and Medicaid allowable (purchase only). 4

5 Bat hroom and Other Pat ient Lifts (E0625, E0636, E0639, E0640, E1035, E1036) When a hydraulic or mechanical pat ient lift or an elect ric pat ient lift is found not to address the individual s medical needs, a different t ype of lift may be needed. The following information is needed to review requests for bathroom and other patient lifts: 1. Fully completed Out pat ient Prior Authorization Request Form or fully completed aut horizat ion request via on-line web portal; 2. A prescription from a licensed practitioner enrolled in the Connecticut Medical Assistance Program (CMAP); 3. A signed letter of medical necessity describing the individual s medical condition as it relates to the need for a specific patient lift system, including t he following: a. Individual s height and weight ; b. Medical evaluat ion by the individual s primary care provider, which may be eit her a specific evaluat ion for a patient lift, signed discharge orders from a hospit al or nursing facilit y, or other evaluat ion, such as t he most recent hist ory and physical examinat ion and subsequent progress not es; and c. Ant icipat ed lengt h of t ime t hat t he individual will need a patient lift. 4. A home evaluat ion wit h recommendat ions from a Connect icut licensed occupat ional therapist, physical therapist, or registered nurse, performed within the three (3) months prior to the submission of t he prior aut horizat ion request, which meet s t he criteria in the above Clinical Guideline. The clinical documentation should include t he following: a. Individual s medical condition and functional status that requires the specific kind of lift requested; b. Descript ion of t his person s ambulat ion, mobilit y, and t ransfer met hod(s), including independence, safet y, amount and t ype of assist ance from ot hers, and reason this method does not meet the recipient s needs; such as postural/ motor control, muscle strength, t one, coordinat ion/ balance, range of mot ion, cardiopulmonary status; c. General st rengt h/ healt h and age of primary caret aker; d. Descript ion of t ype and amount of caret aker support ; e. Ot her f unct ional st rat egies or DME evaluat ed or considered and reason f or ineffect iveness; f. List of all current durable medical equipment ; i.e., current patient lift, wheeled mobility device, stander, walker, hygiene equipment, orthotics, and prosthetics; including manufact urer, model (when available), and special feat ures; dat e of purchase, and the individual s ability independent ly ut ilize; g. Document ed evidence of a comparat ive evaluat ion of various pat ient lift s t hat explains the rationale for the requested patient lifts to address the individual s 5

6 current medical condition and associated functional needs, plans for anticipated medical change; h. Document ed evidence, in t he presence and collaborat ion wit h t he individual s caretaker and evaluat ing healt h care clinician, of satisfactory use of the recommended lift and specific sling or ot her t ype of body support, including safet y, comfort, and funct ion; i. Descript ion of how a patient lift is current ly used or will be used in essent ial areas within the home that address the person s medical needs such transfers between the wheeled mobility device, bed, and/or hygiene location; j. Document ed ant icipat ed changes in t he individual s environment ; k. Document at ion t hat t he lift will fit in all identified essential areas of the home for act ivit ies of daily living; l. Document at ion regarding t he less cost ly alt ernat ives considered and why t hey were rejected; and m. For prior aut horizat ion for a ceiling or wall mount ed lif t s, a schemat ic drawing by the evaluating DME Provider for the pat hway of t he pat ient lift ; writ t en permission from the individual s landlord is required, if applicable. 5. A detailed product description including manufact urer, model/ part number, product description, HCPC code, unit(s), and Medicaid allowable price, and proof of manufacturer s suggested retail price (purchase only). Sling or Seat, Pat ient Lift, Canvas or Nylon (E0621) Slings and seat s for patient lifts have a quantity limit of two (2) per year. Note: An updated evaluation may be requested by Community Health Network if it is determined that the person s medical condition or typical activities of daily tasks have changed since receiving the current patient lift. EFFECTIV E DATE This policy is effective for prior aut horizat ion request s for patient lift systems for individuals covered under the HUSKY Healt h Program beginning April 1, LIMITATIONS N/ A CODES Code E Descript ion Sling or seat, pat ient lif t, canvas or nylon 6

7 E E E E E E E E Pat ient lif t, bat hroom or t oilet, not ot herwise classif ied Pat ient lif t, hydraulic or mechanical, includes any seat, sling, st rap(s) or pad(s) Pat ient lif t, elect ric wit h seat or sling Mult i-positional patient support system, with integrated lift, patient accessible controls Pat ient lif t, moveable f rom room t o room wit h disassembly and reassembly, includes all components/ accessories Pat ient lif t, f ixed syst em, includes all component s/ accessories Mult i-positional patient transfer system, with integrated seat, operated by care giver, patient weight capacity up to and including 300 lbs. Mult i-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs. DEFINITIONS 1. Medically Necessary or Medical Necessit y: (as defined in Connect icut General St at ut es 1 7 b-259b) Those health services required to prevent, identify, diagnose, treat, rehabilitate or ameliorat e an individual's medical condit ion, including ment al illness, or it s effect s, in order t o at t ain or maint ain t he individual's achievable healt h and independent functioning provided such services are: (1) Consist ent wit h generally-accept ed st andards of medical practice that are defined as standards that are based on (A) credible scient ific evidence published in peer-reviewed medical literature that is generally recognized by the relevant medical community, (B)recommendations of a physician-specialt y societ y, (C) t he views of physicians pract icing in relevant clinical areas, and (D) any ot her relevant fact ors; (2) clinically appropriat e in t erms of t ype, frequency, timing, site, extent and duration and considered effective for the individual's illness, injury or disease; (3) not primarily for t he convenience of t he individual, t he individual's healt h care provider or ot her healt h care providers; (4) not more cost ly t han an alt ernat ive service or sequence of services at least as likely t o produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the individual's illness, injury or disease; and (5) based on an assessment of the individual and his or her medical condition 2. Prior Aut horiz at ion: A process for approving covered services prior t o t he delivery of t he service or initiation of the plan of care based on a determination by CHNCT as to whether the requested service is medically necessary ADDITIONAL RESOURCES AND REFERENCES: Collins JW, Nelson A, and Sublet (2006). Safe lift ing and movement of nursing home residents, DHHS (NIOSH) Publication No Cincinnati, Ohio: Nat ional Inst it ut e 7

8 for Occupational Safety and Health. niosh/ docs/ / pdfs/ pdf. Mat z, M. ( ) Analysis of VA Pat ient Handling and Movement Injuries and Prevent ive Programs. Int ernal Veterans Health Administration report to Direct or, Veterans Health Administration, Occupat ional Healt h Program. PatientSafetyCenter/ safepthandling/ FacilityChampionResources.asp. Mat z, M. ( ). Pat ient Handling (Lif t ing) Equipment Coverage and Space Recom m endat ions, V irginia Public Healt h Depart m ent. docs/ employeehealth/ Pt_Hdlg_Design_Equip_Coverage_Spac e_recs.pdf Medicare Nat ional Coverage Det erminat ions Manual, Cent ers for Medicare and Medicaid Services (CMS), Publicat ion , Chapt er 1, Part 4, Sect ion Regulations-and- Guidance/ Guidance/ Manuals/ downloads/ ncd1 0 3 c1 _ part 4.pdf. Nat ional Herit age Insurance Company (NHIC), Corporation. Pat ient lift s. Medicare Local Coverage Art icle No. A Durable Medical Equipment Medicare Administ rat ive Cont ract or, Jurisdict ion A (DME MAC A). Hingham, MA: NHIC; revised January 1, Nat ional Herit age Insurance Company (NHIC), Corporat ion. Pat ient Lif t s Online Tut orial (2012), Durable Medical Equipment Medicare Administrator Cont ract or, Jurisdict ion A (DME MAC A). Hingham, MA: NHIC. dme/ online/ pal_0112/ pal_0112.sht ml. Nat ional Herit age Insurance Company (NHIC), Corp. Pat ient lift s. Medicare Local Cont ract or Det erminat ion (LCD) No. L Durable Medical Equipment Medicare Administrative Contractor (DME MAC) Jurisdiction A. Hingham, MA: NHIC; revised July Nordian Healt hcare Solut ions, Nordian Provider Out reach and Educat ion, (DME MAC) Jurisdict ion D, Pat ient Lift s, February dme/ train/ presentations/ patient_lifts.pdf. Pricing, Dat a Analysis and Coding US Vet erans Healt h Administration. (2003) Pat ient care ergonomics resource guide: Saf e patient handling and movement (Parts 1 and 2). Tampa, FL: Pat ient Saf et y Cent er of Inquiry patientsafetycenter/ safepthandling/ default.asp. Veterans Integrated Service Networks, Patient Safety Center of Inquiry, Tampa Veterans Administration Research and Education Foundation (2014). Technology Resource Guide. Tampa, Florida. safe-patient-handling/ TechnologyResourceGuide.pdf. Wat er, T. R., Nelson, A., Hughes, N., & Menzel, N. (2009). Saf e Pat ient Handling Training for Schools of Nursing, Publicat ion No.: Cincinnati, OH: Nat ional Inst it ut e for Occupat ional Saf et y and Healt h. PUBLICATION HISTORY 8

9 St at us Dat e Action Taken Original Publicat ion March Approved by DSS on March 13, 2015 Rev iewed March Approved at the March 16, 2015 Clinical Quality Sub- Commit t ee Meet ing. Updat ed March 2016 Updat es t o language in int roduct ory paragraph pert aining t o purpose of policy. Updates to Clinical Guideline and Inf ormat ion Required f or Review sect ions pertaining to definit ion of Medical Necessit y and document at ion requirements. Updat es t hroughout policy to reflect import ance of person-centeredness when reviewing requests for these items. Changes to section titled Sling or Seat, Pat ient Lif t, Canvas or Nylon (E ). All changes approved by Clinical Quality Subcommittee on Ap 12, Changes approved by DSS on April 21, Updat ed November 2016 Format changes t o Clinical Guideline sect ion. Changes approved at t he Medical Policy Review Meet ing on Oct ober 2 6, Changes approved at t he December 20, Clinical Qualit y Subcommit t ee meet ing. Approved by DSS on January 3,