A non-invasive positive pressure respiratory assistance (NPPRA) is the administration of positive air pressure, using a nasal and/or oral mask interface which creates a seal, avoiding the use of more invasive airway access (e.g., tracheostomy).
A respiratory assist device (RAD) without backup rate delivers adjustable, variable levels (within a single respiratory cycle) of positive air pressure by way of tubing and a non-invasive interface (such as a nasal or oral facial mask) to assist spontaneous respiratory efforts and supplement the volume of inspired air into the lungs.
A RAD with backup rate delivers adjustable, variable levels (within a single respiratory cycle) of positive air pressure by way of tubing and a non-invasive interface (such as a nasal or oral facial mask) to assist spontaneous respiratory efforts and supplement the volume of inspired air into the lungs.
A RAD may be considered medically necessary for the first three (3) months of therapy for individuals with Restrictive Thoracic Disorders that meet the following criteria:
A RAD may be considered medically necessary for the first three (3) months of therapy for individuals with severe COPD that meet ALL of the following criteria:
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 will be 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 individual accommodation to its use, will usually result in sufficient improvement without need of a back-up rate.
A RAD with back-up device may be considered medically necessary when the following criteria have been met:
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:
Heated and non-heated humidification may be considered medically necessary when prescribed by the treating physician to meet the needs of the individual and when the RAD meets the above criteria.
Non-invasive Open Ventilation (NIOV) System
Non-invasive open ventilation (NIOV) system is considered experimental/investigational and therefore non-covered. The safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.
If the above criteria are not met, the device and related accessories (see Table below) are considered not medically necessary.
For coverage beyond the initial three (3) months of therapy, medical necessity of continued coverage of these devices must occur within 61 to 90 days from the date the therapy was initiated.
Quantities of supplies greater than those identified, as the usual maximum amounts are considered not medically necessary.
A physician must prescribe ALL equipment and accessory durable medical equipment.
See below for accessory quantity level limits.
|Accessory||Usual Maximum Replacement|
|A4604**||1 per 3 months|
|A7027**||1 per 3 months|
|A7028**||2 per 1 month|
|A7029**||2 per 1 month|
|A7030**||1 per 3 months|
|A7031**||1 per 1 month|
|A7032**||2 per 1 month|
|A7033**||2 per 1 month|
|A7034**||1 per 3 months|
|A7035*||1 per 6 months|
|A7036*||1 per 6 months|
|A7037**||1 per 3 months|
|A7038**||2 per 1 month|
|A7039*||1 per 6 months|
|A7044*||1 per 3 months|
|A7045*||1 per 3 months|
|A7046*||1 per 6 months|
* Allows for a 10 day delivery before run-out
** Allowing for a 3 month supply
Total payments for a rental items may not exceed its allowable purchase price, except for those items identified as life-sustaining DME.
For the purpose of this policy, arterial blood gas, sleep oximetry, and polysomnographic studies may not be performed by a DME supplier. A DME supplier is not considered a qualified provider or supplier of these tests for purposes of this policy’s coverage and payment guidelines. This prohibition does not extend to the results of studies conducted by hospitals certified to do such tests.
Refer to Medical Policy Devices Used for the Treatment of Sleep Apnea in Adults for additional information.
Covered Diagnosis Codes for Procedure Codes E0470 and E0471