Respiratory Assist Devices CPAP-BiPAP - Health Plan of Nevada

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. Sleep oximetry demonstrates oxygen saturation less-than-or-equal-to 88% for at least five continuous minutes, done while breathing the individual’s usual FIO2, or c. Maximal inspiratory pressure for progressive neuromuscular disease is, less than 60 cm H20 or forced vital capacity is less than 50% predicted, and 1. Chronic obstructive pulmonary disease (COPD) does not contribute significantly to the individual’s pulmonary limitation. 2. If the above criteria are met, either an E0470 or E0471 device will be covered for individuals within this group of conditions for the first three months of NPPRA therapy. B. Severe COPD 1. An arterial blood gas PaCO2, was done while individual was awake and breathing the individual’s usual FIO2, is greater-than-or-equal-to 52 mm Hg; and 2. Sleep oximetry demonstrates oxygen saturation less-than-or-equal-to 88% for at least five continuous minutes, done while breathing oxygen at 2 liter per minute or the individual’s usual FIO2, whichever is higher; and 3. Obstructive Sleep Apnea (OSA) (and treatment with CPAP) has been considered and ruled out prior to initiating therapy. 4. If all of the above criteria for individuals with COPD are met, an E0470 device will be covered for the first three months of NPPRA therapy. 5. An E0471 device will not be covered for an individual with COPD during the first two months, because therapy with an E0470 device with proper adjustments of the device’s setting and individual accommodation to its use will usually result in sufficient improvement without the need of a back-up rate. C. Central Sleep Apnea (CSA) or Complex Sleep Apnea (CompSA) (apnea not due to airway obstruction) 1. Prior to initiating therapy, a complete facility-based, attended polysonigraph (PSG) must be performed documenting the following: a. The diagnosis of CSA or CompSA (see definitions in Appendices section); b. The ruling out of CPAP as effective therapy if either CSA or OSA is a component of the initially observed sleep-associated hypoventilation; and c. Significant improvement of the sleep-associated hypoventilation with the use of an E0470 or E0471 device on the settings that will be prescribed for initial use at home, while breathing the individual’s usual FIO2. 2. If all above criteria are met, either an E0470 or E0471 device (based upon the judgment of the treating physician) will be covered for individuals with documented CSA or CompSA for the first three months of NPPRA therapy. Obstructive Sleep Apnea (OSA) 1. A complete facility-based, attended polysomnogram, has established the diagnosis of obstructive sleep apnea according to the following criteria: a. The Apnea-Hypopnea Index (AHI) is greater-than-or-equal-to15 events per hour; or Respiratory Assist Devices_CPAP-BiPAP Page 2 of 9
. The AHI is greater-than-or-equal-to 5 to less-than-or-equal-to14 events per hour with documented symptoms of: i. Excessive daytime sleepiness, or ii. Impaired cognition, mood disorders, insomnia, or iii. Hypertension, or iv. Ischemic heart disease, or v. History of stroke, or vi. Greater than 20 episodes of oxygen desaturation less than 85% during a full night sleep study or any one episode of oxygen desaturation less than 70%. c. If the above criteria are met, an E0470 device will be covered for the first 60 days of NPPRA therapy. Note: The Apnea-Hypopnea Index (AHI) is equal to the average number of episodes of apnea and hypopnea per hour and must be based on a minimum of 2 hours of sleep recorded by polysomnography using actual recorded hours of sleep (i.e., the AHI may not be extrapolated or projected). For the purposes of this protocol, Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation. 1. For All Product Lines – either a non-heated (E0561) or a heated (E0562) humidifier is covered when ordered by the treating physician for use with a covered E0601 device. 2. CPAP must be prescribed and ordered by the treating physician (MD/DO). 3. Polysomnography must be performed in a facility-based sleep study laboratory, and not in the home or in a mobile facility. 4. CPAP-BIPAP is authorized for 60 days to determine individual tolerance to the equipment. 5. Continued coverage of an E0601 device beyond the 60 days requires the supplier ascertain from either the member or the treating physician that the member is to use the CPAP device. 6. All CPAP-BIPAP devices and accessories must be ordered through the contracted DME vendor 7. Refer to Protocol PUL004, Polysomnography & Portable Monitoring for evaluation of Sleep Related Breathing Disorders . CPAP-BiPAP devices are not medically necessary when the above criteria have not been met. An E0471 device is not medically necessary if the primary diagnosis is Obstructive Sleep Apnea (OSA). MEDICARE & MEDICAID COVERAGE RATIONALE Medicare has a National Coverage Determination for Continuous Positive Airway Pressure (C-PAP) Therapy for Obstructive Sleep Apnea (OSA). The National Coverage Determination is as follows: Respiratory Assist Devices_CPAP-BiPAP Page 3 of 9
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Respiratory Assist Devices CPAP-BiPAP - Health Plan of Nevada

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