Ventilator Guidelines

Effective Dec. 1, 2017, the South Carolina Department of Health and Human Services (SCDHHS) will add criteria and prior authorization guidelines for ventilators to the Durable Medical Equipment (DME) Provider Manual for DME providers. This policy will be posted in the DME Provider Manual located on the SCDHHS website, www.scdhhs.gov.

The ventilator policy guidelines are as follows:

• Invasive (tracheostomy tube) and non-invasive (mask, chest shell) ventilators will be considered for rental only with prior authorization and documentation of medical necessity indicating a clinical need for mechanical ventilation. Consideration of reimbursement is based on meeting the following criteria:  
  • The beneficiary is medically dependent on a ventilator for at least six hours per day.
    • The beneficiary has a diagnosis of at least one of the following as supported by medical records:
    • Chronic respiratory failure
    • Spinal cord injury
    • Neuromuscular disorder/disease
    • Thoracic restrictive disorder/disease
  • The beneficiary has adequate support services or a caregiver which would allow for safe use of the ventilator.
• A ventilator for the treatment of obstructive sleep apnea will only be considered for reimbursement upon a case-by-case review.  
• Requests for a ventilator must be submitted to KEPRO for prior authorization for Medicaid fee-for-service (FFS) beneficiaries. Instructions are located in Section 2, Medicaid Prior Approval (PA) from KEPRO, of the DME Provider Manual. South Carolina Medicaid managed care organizations (MCOs) should be contacted directly for information on their ventilator prior authorization requirements.

Please refer any questions or concerns regarding this bulletin to the Provider Service Center at (888) 289-0709).

Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.