Items include, but not limited to the following:
Oxygen – Concentrators, Portable Tanks, Home Fill Units, Liquid Oxygen:
Common Diagnosis: COPD (496), CHF (428.0) and
Pneumonia/three months (486)
Insurance Standard:
· A patient qualifies for 12 months if the following criteria are met:
saturation levels are performed at a doctor’s office, hospital or qualified lab.
1. Patient pO2 is less than or equal to 55 mmHg or their spO2 is less than or equal to 88%.
2. Patient qualifying data (saturation at rest and required liter flow) is reported within 30 days of an
outpatient office visit or within 48 hours of hospital discharge.
3. Patient saturation levels are performed at a doctor’s office, hospital or qualified lab.
Nebulizer – Desktop and Portable Units:
Common Adult Diagnosis: COPD (496), Asthma (493.90) and Chronic Bronchitis (491.0)
Common Pediatric Diagnosis: RSV (079.6), Asthma (493.90) and Acute Bronchitis (466.1)
Insurance Standard:
· Patient qualifies for coverage if the nebulizer is deemed medically necessary and the appropriate medication
solution is ordered.
Other Considerations:
· Pneumonia and wheezing are not covered diagnoses.
Overnight Pulse Oximetry Testing:
Common Diagnoses: COPD (496), Asthma (493.90) and Chronic Bronchitis (491.0)
Insurance Standard:
· Patient qualifies for coverage if there is suspicion of nocturnal desaturation.
· Test can be completed every thirty days.
· Test is not covered by Medicare.
Positive Airway Pressure (PAP) Devices – BiPAP/CPAP:
Common Diagnosis: Obstructive Sleep Apnea (327.23), OSA (327.23)
Insurance Standard:
· BiPAP/CPAP machines and accessories are covered if the patient has:
1. A face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the patient for
obstructive sleep apnea.
2. A Medicare-covered sleep test that meets either of the following criteria:
- The Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to
15 events per hour with a minimum of 30 events.
- The AHI or RDI is greater than or equal to five and less than or equal to 14 events per hour with a
minimum of 10 events. Documentation of excessive daytime sleepiness, impaired cognition, mood
disorder, insomnia, hypertension, ischemic heart disease, or history of stroke is also required.
Other Considerations:
· Other diagnoses may be covered, such as Central Sleep Apnea, COPD, and neuromuscular diseases.
More information on these diagnoses are available upon request.
Suction Pump:
Common Diagnoses: COPD (496), Tracheostomy (v44.0), ALS (335.20), various neuromuscular disorders.
Insurance Standard:
· Patient qualifies for coverage if experience one of the following events:
1. A tracheostomy
2. Difficulty raising and clearing secretions due to cancer or surgery of mouth or throat.
3. Dysfunction of swallowing muscles.
4. Patient is unconscious.
Oxygen – Concentrators, Portable Tanks, Home Fill Units, Liquid Oxygen:
Common Diagnosis: COPD (496), CHF (428.0) and
Pneumonia/three months (486)
Insurance Standard:
· A patient qualifies for 12 months if the following criteria are met:
saturation levels are performed at a doctor’s office, hospital or qualified lab.
1. Patient pO2 is less than or equal to 55 mmHg or their spO2 is less than or equal to 88%.
2. Patient qualifying data (saturation at rest and required liter flow) is reported within 30 days of an
outpatient office visit or within 48 hours of hospital discharge.
3. Patient saturation levels are performed at a doctor’s office, hospital or qualified lab.
Nebulizer – Desktop and Portable Units:
Common Adult Diagnosis: COPD (496), Asthma (493.90) and Chronic Bronchitis (491.0)
Common Pediatric Diagnosis: RSV (079.6), Asthma (493.90) and Acute Bronchitis (466.1)
Insurance Standard:
· Patient qualifies for coverage if the nebulizer is deemed medically necessary and the appropriate medication
solution is ordered.
Other Considerations:
· Pneumonia and wheezing are not covered diagnoses.
Overnight Pulse Oximetry Testing:
Common Diagnoses: COPD (496), Asthma (493.90) and Chronic Bronchitis (491.0)
Insurance Standard:
· Patient qualifies for coverage if there is suspicion of nocturnal desaturation.
· Test can be completed every thirty days.
· Test is not covered by Medicare.
Positive Airway Pressure (PAP) Devices – BiPAP/CPAP:
Common Diagnosis: Obstructive Sleep Apnea (327.23), OSA (327.23)
Insurance Standard:
· BiPAP/CPAP machines and accessories are covered if the patient has:
1. A face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the patient for
obstructive sleep apnea.
2. A Medicare-covered sleep test that meets either of the following criteria:
- The Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to
15 events per hour with a minimum of 30 events.
- The AHI or RDI is greater than or equal to five and less than or equal to 14 events per hour with a
minimum of 10 events. Documentation of excessive daytime sleepiness, impaired cognition, mood
disorder, insomnia, hypertension, ischemic heart disease, or history of stroke is also required.
Other Considerations:
· Other diagnoses may be covered, such as Central Sleep Apnea, COPD, and neuromuscular diseases.
More information on these diagnoses are available upon request.
Suction Pump:
Common Diagnoses: COPD (496), Tracheostomy (v44.0), ALS (335.20), various neuromuscular disorders.
Insurance Standard:
· Patient qualifies for coverage if experience one of the following events:
1. A tracheostomy
2. Difficulty raising and clearing secretions due to cancer or surgery of mouth or throat.
3. Dysfunction of swallowing muscles.
4. Patient is unconscious.