VENTILATOR (RESPIRATOR) - RENTAL

GENERAL NOTES PRE-AUTHORIZATION REQUIRED UNLESS OTHERWISE INDICATED. COMMAS APPEARING IN THE "PRESCRIBER REQUIRED" AND "RECOMMENDER REQUIRED" COLUMNS INDICATE OR, EG. "MD", "RN" MEANS MD OR RN. FOR ONGOING RENTAL AGREEMENTS, IF DETERMINED THE EQUIPMENT RENTAL HAS/WILL RESULT IN PAYMENTS EXCEEDING THE PURCHASE PRICE, THE RENTAL AGREEMENT SHOULD, WHERE POSSIBLE AND WHEN DETERMINED APPROPRIATE UNDER THE CIRCUMSTANCES, BE TERMINATED AND THE EQUIPMENT PURCHASED. THE RENTAL FEE OF THE SYSTEM IS TO BE DEDUCTED FROM THE PURCHASE PRICE (IF APPLICABLE). WHERE REGISTERED POLYSOMNOGRAPHIC TECHNOLOGIST (PG), REGISTERED NURSE (RN) OR LICENSED PRACTICAL NURSE (LP)/REGISTERED PRACTICAL NURSE (RO) ARE INDICATED AS A REQUIRED RECOMMENDER, THE RECOMMENDER MUST BE WITHIN THEIR SCOPE OF PRACTICE IN THEIR PROVINCE/TERRITORY. WHERE A REQUIRED RECOMMENDER IS INDICATED, A REPORT MUST BE SUBMITTED AND INCLUDE: A. DIAGNOSIS B. CURRENT PRESCRIPTION (A PRESCRIPTION IS VALID FOR ONE YEAR AFTER THE DATE WRITTEN) C. RESPIRATORY STATUS FOR PAP THERAPY: SUMMARY OF FINDINGS FROM LEVEL 3 SLEEP STUDY AND/OR OXIMETRY, SIGNS AND SYMPTOMS OF OBSTRUCTIVE SLEEP APNEA, DEVICE SETTINGS, AND/OR ANY OTHER RELEVANT INFORMATION FOR OXYGEN THERAPY: ALL FINDINGS FROM THE RESPIRATORY ASSESSMENT, INCLUDING VITAL SIGNS, INSPECTION FINDINGS, PALPATION FINDINGS, AUSCULTATION FINDINGS, OXYGEN RATE, AND/OR ANY OTHER RELEVANT INFORMATION. D. INTERPRETATION OF TEST RESULTS (COPIES OF THESE REPORTS ARE NOT REQUIRED) E. TESTING/TRIAL RESULTS CONFIRMING IMPROVEMENT IN CLIENT S SLEEP CONDITION FOR PAP THERAPY (BASED ON A MINIMUM 30-DAY TRIAL PERIOD) F. MAKE, MODEL AND DETAILED COST OF REQUESTED ITEMS G. SIGNATURES WITH DESIGNATION H. A BENEFIT NOT LISTED IN THE BENEFIT GRID MAY BE CONSIDERED BY EXCEPTION WITH MEDICAL JUSTIFICATION. PROVIDERS MUST SUPPLY TRAINING ON THE SAFE USE OF OXYGEN THERAPY AND RESPIRATORY EQUIPMENT AND ENSURE THAT THE CLIENT CONTINUES TO USE THE EQUIPMENT PROPERLY DURING FOLLOW-UP APPOINTMENTS. SPECIAL NOTES NOTE 19 - THE RENTAL APPROVAL PERIOD FOR VENTILATORS MUST NOT EXCEED 4 MONTHS UNLESS ACCOMPANIED BY A WRITTEN JUSTIFICATION SUPPORTING THE NEED.