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
|
