(1) The medicaid agency covers the purchase of oximeters for clients eighteen years of age and older with prior authorization as follows:

(a) One standard oximeter, per client, every twenty-four months; or

(b) One enhanced oximeter, per client, every thirty-six months.

(2) The medicaid agency covers the purchase of oximeters for clients seventeen years of age and younger, in the home, as follows:

(a) When the client meets one of the following clinical criteria:

(i) Has chronic lung disease and is on supplemental oxygen;

(ii) Has a compromised or artificial airway; or

(iii) Has chronic lung disease requiring ventilator or bi-level respiratory assist device; and

(b) The following limitations apply:

(i) One standard oximeter, per client, every twenty-four months, without prior authorization; or

(ii) One enhanced oximeter, per client, every thirty-six months, with expedited prior authorization.

(3) The medicaid agency pays for replacement supplies as follows:

(a) Cables for enhanced oximeter only, limited to two per client per year. Prior authorization (PA) is required.

(b) Probes.

(i) Nondisposable, limited to one per client every one hundred eighty days.

(ii) Disposable, limited to four per client every thirty days.