Reproduced with permission. insurance programs. "JavaScript" disabled. REVISION EFFECTIVE DATE: 08/08/2021COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:Removed: etc. from initial coverage statement for E0470 or an E0471 RADRevised: Situation 1 and 2 revised Group II to severe COPD beneficiariesRevised: Situation 1 criterion B to proper LCD title, Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea for E0471Revised: Hypoventilation Syndrome criterion D to proper LCD title, Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea for E0470 and E0471Revised: Header from VENTILATOR WITH NOINVASIVE INTERFACES to VENTILATORRevised: The CMS manual reference to CMS Pub. 1 Generally, Medicare is for people 65 or older. If your equipment is worn out, Medicare will only replace it if you have had the item in your possession for its whole lifetime. A52517 - Respiratory Assist Devices - Policy Article, A58822 - Response to Comments: Respiratory Assist Devices - DL33800, A55426 - Standard Documentation Requirements for All Claims Submitted to DME MACs, RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITHOUT BACKUP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE), RESPIRATORY ASSIST DEVICE, BI-LEVEL PRESSURE CAPABILITY, WITH BACK-UP RATE FEATURE, USED WITH NONINVASIVE INTERFACE, E.G., NASAL OR FACIAL MASK (INTERMITTENT ASSIST DEVICE WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE), TUBING WITH INTEGRATED HEATING ELEMENT FOR USE WITH POSITIVE AIRWAY PRESSURE DEVICE, COMBINATION ORAL/NASAL MASK, USED WITH CONTINUOUS POSITIVE AIRWAY PRESSURE DEVICE, EACH, ORAL CUSHION FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, EACH, NASAL PILLOWS FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, PAIR, FULL FACE MASK USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACH, FACE MASK INTERFACE, REPLACEMENT FOR FULL FACE MASK, EACH, CUSHION FOR USE ON NASAL MASK INTERFACE, REPLACEMENT ONLY, EACH, PILLOW FOR USE ON NASAL CANNULA TYPE INTERFACE, REPLACEMENT ONLY, PAIR, NASAL INTERFACE (MASK OR CANNULA TYPE) USED WITH POSITIVE AIRWAY PRESSURE DEVICE, WITH OR WITHOUT HEAD STRAP, HEADGEAR USED WITH POSITIVE AIRWAY PRESSURE DEVICE, CHINSTRAP USED WITH POSITIVE AIRWAY PRESSURE DEVICE, TUBING USED WITH POSITIVE AIRWAY PRESSURE DEVICE, FILTER, DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICE, FILTER, NON DISPOSABLE, USED WITH POSITIVE AIRWAY PRESSURE DEVICE, ORAL INTERFACE USED WITH POSITIVE AIRWAY PRESSURE DEVICE, EACH, EXHALATION PORT WITH OR WITHOUT SWIVEL USED WITH ACCESSORIES FOR POSITIVE AIRWAY DEVICES, REPLACEMENT ONLY, WATER CHAMBER FOR HUMIDIFIER, USED WITH POSITIVE AIRWAY PRESSURE DEVICE, REPLACEMENT, EACH, HUMIDIFIER, NON-HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE, HUMIDIFIER, HEATED, USED WITH POSITIVE AIRWAY PRESSURE DEVICE. We offer a wide selection of durable medical equipment for orthopedic conditions, including: Crutches and walkers. If your session expires, you will lose all items in your basket and any active searches. HCPCS Code A9284 for Spirometer, non-electronic, includes all accessories as maintained by CMS falls under Miscellaneous Supplies and Equipment. - If the AHI or CAHI is calculated based on less than 2 hours of continuous recorded sleep, the total number of recorded events used to calculate the AHI or CAHI must be at least the number of events that would have been required in a 2-hour period (i.e., greater than or equal to 10 events). Select. anesthesia procedure services that reflects all Items delivered without a valid, documented refill request will be denied as not reasonable and necessary. Refer to the repair and replacement information in the Supplier Manual for additional information. EY - No physician or other licensed health care provider order for this item or service, GA Waiver of liability statement issued as required by payer policy, individual case, GZ - Item or service expected to be denied as not reasonable and necessary, KX - Requirements specified in the medical policy have been met. Medicare provides coverage for items and services for over 55 million beneficiaries. A facility-based PSG or HST demonstrates oxygen saturation less than or equal 88% for greater than or equal to 5 minutes of nocturnal recording time (minimum recording time of 2 hours) that is not caused by obstructive upper airway events i.e., AHI less than 5 while using an E0470 device. Some of these services not covered by Original Medicare may be covered by a Medicare Advantage Plan (like an HMO or PPO). Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. After that analysis, we determined that the home sleep test information in Respiratory Assist Devices LCD (L33800) was duplicative. If all of the above criteria are met, either an E0470 or an E0471 device (based upon the judgment of the treating practitioner) will be covered for the first three months of therapy. Under 65 with certain disabilities. An E0471 device will be covered for a beneficiary with COPD in either of the two situations below, depending on the testing performed to demonstrate the need. MACs develop an LCD when there is no national coverage determination (NCD) (e.g., when an item or service is new) or when there is a need to further define an NCD for the specific jurisdiction. var url = document.URL; There is documentation in the beneficiarys medical record of a neuromuscular disease (for example, amyotrophic lateral sclerosis) or a severe thoracic cage abnormality (for example, post-thoracoplasty for TB). The Tracking Sheet modal can be closed and re-opened when viewing a Proposed LCD. beneficiaries and to individuals enrolled in private health Medicare has four parts: Part A (Hospital Insurance) Part B (Medicare Insurance) (Social Security Act 1834(a)(3)(A)) This means that products currently classified as HCPCS code E0465, E0466, or E0467 when used to provide CPAP or bi-level PAP (with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the FSS payment category. Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD. Learn about what items and services aren't covered by Medicare Part A or Part B. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions described in this RAD policy will be denied as not reasonable and necessary. Medicare program. A RAD (E0470, E0471) is covered for those beneficiaries with one of the following clinical disorders: restrictive thoracic disorders (i.e., neuromuscular diseases or severe thoracic cage abnormalities), severe chronic obstructive pulmonary disease (COPD), CSA or CompSA, or hypoventilation syndrome, as described in the following section. This list only includes tests, items and services that are covered no matter where you live. is a9284 covered by medicare. Find out what we're doing to improve Medicare for all Australians. The purpose of a Local Coverage Determination (LCD) is to provide information regarding reasonable and necessary criteria based on Social Security Act 1862(a)(1)(A) provisions. According to the Centers for Medicare & Medicaid Services (CMS), Medicare's reimbursement rate on average is roughly 80 percent of the total bill. The carrier assigned CMS type of service which Is an AFO covered by Medicare? The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. The following table represents the usual maximum amount of accessories expected to be reasonable and necessary: Billing for quantities of supplies greater than those described in the policy as the usual maximum amounts, will be denied as not reasonable and necessary. The beneficiarys prescribed FIO2 refers to the oxygen concentration the beneficiary normally breathes when not undergoing testing to qualify for coverage of a Respiratory Assist Device (RAD). units, and the conversion factor.). CDT is a trademark of the ADA. three-way stander), any size including pediatric, with or without wheels, Standing frame system, mobile (dynamic stander), any size including pediatric, Safety equipment (e.g., belt, harness or vest), Restraints, any type (body, chest, wrist or ankle), Continuous passive motion exercise device for use other than knee, Injection, medroxyprogesterone acetate for contraceptive use, 150 mg, Drug administered through a metered dose inhaler, Prescription drug, oral, nonchemotherapeutic, NOS, Knee orthosis, elastic with stays, prefabricated, Knee orthosis, elastic or other elastic type material, with condylar pads, prefabricated, Knee orthosis, elastic knee cap, prefabricated, Orthopedic footwear, ladies shoes, oxford, each, Orthopedic footwear, ladies shoes, depth inlay, each, Orthopedic footwear, ladies shoes, hightop, depth inlay, each, Orthopedic footwear, mens shoes, oxford, each, Orthopedic footwear, mens shoes, depth inlay, each, Orthopedic footwear, mens shoes, hightop, depth inlay, each, Shoulder orthosis, single shoulder, elastic, prefabricated, Shoulder orthosis, double shoulder, elastic, prefabricated, Elbow orthosis elastic with stays, prefabricated, Wrist hand finger orthosis, elastic, prefabricated, Prosthetic donning sleeve, any material, each, Tension Ring, for vacuum erection device, any type, replacement only, each, Azithromycin dehydrate, oral, capsules/powder, 1 gram, Injection, pegfilgrastim-jmdb, biosimilar, (fulphila), 0.5 mg, Injection, filgrastim-aafi, biosimilar, (nivestym), 1 mg, Hand held low vision aids and other nonspectacle mounted aids, Single lens spectacle mounted low vision aids, Telescopic and other compound lens system, including distance vision telescopic, near vision telescopes and compound microscopic lens system, Repair/modification of augmentative communicative system or device (excludes adaptive hearing aid), Leg, arm, back and neck braces (orthoses), and artificial legs, arms, and eyes, including replacement (prostheses), Oral antiemetic drugs (replacement for intravenous antiemetics). or a code that is not valid for Medicare to a LICENSE FOR USE OF "PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY", (CPT) (Refer to the Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea LCD for information about E0470 coverage for obstructive sleep apnea. Payment for a RAD device for the treatment of the conditions specified in this policy may be contingent upon an evaluation for the diagnosis sleep apnea (Obstructive Sleep Apnea, Central Sleep Apnea and/or Complex Sleep Apnea).
2022-11-07