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LCD - Ventilator

Coverage Summary

  1. Written order prior to delivery
  2. Pressure support ventilator with volume control, may include pressure control mode for use with non-invasive or invasive interface is covered for treatment of:
  • Neuromuscular disease
  • Thoracic restrictive disease
  • Chronic respiratory failure consequent to chronic obstructive pulmonary disease

Order Requirements (E0463-Invasive Vent / E0464 Non-Invasive Vent)

  1. Patient Name
  2. Specific description of ordered items to be delivered
  3. Method of delivery (ie, via mask or tracheostomy)
  4. Prescribed settings
  5. Prescribed frequency of use
  6. Length of Medical Need
  7. Treating Physician’s NPI
  8. Treating physician’s legible signature (personally written or electronically signed by the physician, stamps are not accepted by insurance)
  9. Treating physician’s legible signature date (personally written or electronically signed by the physician, stamps are not accepted by insurance)
  10. Start date of the order – if different than signature date.

Coverage Detail

Pressure support ventilator with volume control, may include pressure control mode for use with non-invasive or invasive interface is covered for treatment of:

  • Neuromuscular disease
  • Thoracic restrictive disease
  • Chronic respiratory failure consequent to chronic obstructive pulmonary disease

Both positive and negative pressure types included.

Each of these disease categories are comprised of conditions that can vary from severe and life-threatening to less serious forms. These disease groups may appear to overlap conditions described in the Respiratory Assist Devices LCD but they are not overlapping.

Choice of an appropriate device i.e., a ventilator versus a bi-level PAP device is made based upon the severity of the condition. CMS distinguished the use of respiratory product types in a National Coverage Analysis Decision Memo (CAG-00052N) in June 2001 saying that RAD (Respiratory Assistance Device) is “distinguished from ventilation in a patient for whom interruption or failure of respiratory support leads to death.”

  • The conditions described in the Respiratory Assistance Devices (RAD) local coverage determination are not life-threatening conditions where interruption of respiratory support would quickly lead to serious harm or death.
  • The RAD policy describes clinical conditions that require intermittent and relatively short durations of respiratory support.
  • Thus, conditions that require intermittent and relatively short durations of respiratory support would not be eligible for reimbursement even though the ventilator equipment may have the capability of operating in a bi-level PAP mode.
  • Bi-level PAP devices are considered as reasonable and necessary in intermittent and relatively short respiratory support needs.

NOTE:

  • Ventilators set with a BIPAP setting are non-covered as BIPAP is appropriate device for settings.