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Home > Disability > NYS Assistive Technology Project > Archives > Medicaid Air Conditioner Prior Approval Guidelines (1997)

Medicaid Air Conditioner Prior Approval Guidelines (1997)

STATE OF NEW YORK - DEPARTMENT OF HEALTH
OFFICE OF MEDICAID MANAGEMENT
INTEROFFICE MEMORANDUM

To:    Bob Rydzyk, Ron Sharp, Beth Eisenhandler, Alan Cornet, Jeffrey Vallon

From:    Vince Martiniano, HPA

Subject: Air Conditioner Prior Approval Guidelines

Date:    July 23, 1997

These prior approval guidelines are provided to assure consistency in reviewing requests for Medicaid coverage of air conditioners. Air conditioners are not considered to have a primary medical purpose and clearly do not meet the definition of durable medical equipment as defined in 18 NYCRR 505.5(a)(1). This definition is also reflected in MMIS Provider Manual for DME in Section 2.2.2.B and forms a basis for Medicaid's long-standing policy of not generally approving requests for payment of air conditioners. However, it has also been the policy to review and prior approve payment of air conditioners if the individual case meets "medically necessary" criteria spelled out in Social Services Law, Section 365-a(2). To assist in determining medical necessity, the following factors should be considered:

Does the ordering physician persuasively demonstrate (with documented evidence of an existing medical condition) that air conditioner control of room temperature and humidity is required as a part of the comprehensive treatment plan and failure to provide this element of care presents a severe risk to life or substantially exacerbates a disability.

Is the air conditioner clearly required to alleviate or prevent the exacerbation of an established clinical condition for which the only alternative medical treatment would be of a more extensive nature, such as hospitalization?

Is the patient's clinical condition directly affected by or related to ambient temperature?

Is the patient confined to home; what are the physical activity restrictions; what is his/her cardiac status and medical prognosis?

Is the primary purpose of the request intended to enhance the patient's general comfort rather than to address a specific medical problem?

If it is determined that prior approval was warranted due to established medical necessity, consideration of the type, size and costs need to be pursued. Only room size units will be approved with maximum capacity of about 7,000 BTU or 1/2 BTU per cubic foot of room volume. The DME vendor should be required to submit a standard prior approval form with invoice (usually from another retail supplier.) Medicaid would pay acquisition cost plus an administration/installation fee of $50 or 10% of cost, whichever is less. Since there is a high potential that the air conditioner will be used for non-medical purposes, care should be given to examine the file for evidence of past air conditioner approvals and to review the nature of previously approved DME items.

cc:    Dr. Guy
       Ms. vonBieberstein
       Ms. DuBois
       Mr. Van Orden

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