Or. Admin. Code § 410-122-0658

Current through Register Vol. 63, No. 11, November 1, 2024

Section 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:

(A) Ulceration due to chronic venous insufficiency;

(B) Varicose veins with ulcer or inflammation;

(C) Phlebitis/thrombophlebitis;

(D) Deep vein thrombosis (DVT) prophylaxis during pregnancy and postpartum or immobilization due to surgery, trauma, or debilitation;

(E) Funded lymphedema conditions; and

(F) Edema following a covered surgery, fracture, burns, or other trauma;

(b) A gradient compression stocking may be covered when it is used to secure a primary dressing over an open venous stasis ulcer that is currently being treated by a practitioner and requires medically necessary debridement and when the gradient stocking delivers compression less than 50 mmHg;

(c) Two gradient compression stockings/sleeves per affected limb may be provided at dispensing (the second one is for use while the first one is being laundered);

(d) Replacement stockings/sleeves are limited to two per affected limb every six months. Requests for quantities that exceed this amount require detailed medical documentation (e.g., change in size, unusual drainage, wear that renders them ineffective);

(e) Custom-made gradient compression stockings/sleeves require prior authorization with documentation that supports that the treating practitioner has considered ready-made gradient compression stockings/sleeves and the reason why they will not meet the medical needs of the client.

(f) The following services are not covered:

(A) Antiembolism stockings (A4490-A4510);

(B) Garter belts (A6544);

(C) Stockings/sleeves for the following conditions:

(i) Solely for the purpose of air travel;

(ii) Treatment of non-funded lymphedema conditions;

(iii) Venous insufficiency without stasis ulcers;

(D) Support hose (pantyhose).

(2) Documentation Requirements: Medical records that support the conditions of coverage are met, as specified in this rule, shall be kept on file by the durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) provider and made available to the Division on request.

(3) Table 122-0658

Or. Admin. Code § 410-122-0658

DMAP 17-2008, f. 6-13-08, cert. ef. 7-1-08; DMAP 13-2010, f. 6-10-10, cert. ef. 7-1-10; DMAP 59-2015, f. 10-28-15, cert. ef. 11/1/2015; DMAP 66-2023, minor correction filed 08/11/2023, effective 8/11/2023; DMAP 101-2023, amend filed 12/29/2023, effective 1/1/2024; DMAP 26-2024, minor correction filed 01/04/2024, effective 1/4/2024

Tables referenced are available from the agency.

To view attachments referenced in rule text, click here to view rule.

Statutory/Other Authority: ORS 413.042 & 414.065

Statutes/Other Implemented: ORS 414.065