A RAD may be considered medically necessary for the first three (3) months of therapy for individuals with severe COPD when
ALL
of the following criteria are met:
-
An arterial blood gas PaCO2, done while awake and breathing the individual's prescribed FIO2, is equal to or greater than 52 mm Hg;
and
-
Sleep oximetry demonstrates oxygen saturation level equal to or less than 88% for at least five (5) minutes, done while breathing oxygen at two (2) liters per minute (LPM) or the individual's prescribed FIO2, whichever is higher;
and
- Prior to initiating therapy, obstructive sleep apnea (OSA) and treatment with continuous positive airway pressure (CPAP) has been considered and ruled out.
If a RAD with backup rate is billed, but the criteria for a RAD without backup rate device are met, payment will be based on the RAD without backup rate.
A RAD with backup rate device is considered not medically necessary for an individual with COPD during the first two (2) months.
Note: Therapy with a RAD without back-up device with proper adjustments of the settings, and patient accommodation to its use, will usually result in sufficient improvement without need of a back-up rate.
An RAD
with
back-up device may be considered medically necessary when
ALL
of the following criteria have been met:
-
The individual has used an RAD without back-up for 61 days;
and
-
An arterial blood gas PaCO2 is repeated while the individual is awake and breathing their prescribed FIO2 and the level remains 52 mm Hg;
and
- A sleep oximetry, while the individual is breathing with the RAD without back-up device demonstrates O2 saturation of less than 88% for at least five (5) continuous minutes, done while breathing oxygen at two (2) LPM or the individual's prescribed FIO2, whichever is higher.
A RAD with a back-up device not meeting the criteria as indicated in this policy is considered not medically necessary.
Procedure Codes
A4604 | A7027 | A7028 | A7029 | A7030 | A7031 | A7032 |
A7033 | A7034 | A7035 | A7036 | A7037 | A7038 | A7039 |
A7044 | A7045 | A7046 | E0470 | E0471 | E0472 | S8186 |
A RAD may be considered medically necessary for the first three (3) months of therapy for those individuals with central sleep apnea (CSA) that have had an attended polysomnogram, performed on stationary equipment
and
meet
ALL
of the following criteria:
-
The diagnosis of CSA;
and
-
The exclusion of obstructive sleep apnea (OSA) as the predominant cause of sleep-associated hypoventilation;
and
-
The ruling out of CPAP as effective therapy if OSA is a component of the sleep-associated hypoventilation;
and
- Significant improvement of the sleep-associated hypoventilation with the use of either RAD device on the settings that will be prescribed for initial use at home, while breathing the individual's prescribed FIO2.
A RAD not meeting the criteria as indicated in this policy is considered not medically necessary.
Procedure Codes
A4604 | A7027 | A7028 | A7029 | A7030 | A7031 | A7032 |
A7033 | A7034 | A7035 | A7036 | A7037 | A7038 | A7039 |
A7044 | A7045 | A7046 | E0470 | E0471 | E0472 | S8186 |
