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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that ventilators may be covered when they are medically necessary for patients who have
neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to chronic obstructive
pulmonary disease (COPD). You can find this rule in the Medicare National Coverage Determinations Manual,
Chapter 1, Section 280.1.
The rules also say that the decision to use a ventilator or a bi-level positive airway pressure device is made
based upon the specifics of each person's medical condition. There must be enough detailed information in the
medical record to justify the treatment selected. You can find this rule in the Local Coverage Determination
(LCD): Respiratory Assist Devices (L33800), effective for services performed on or after January 1, 2017.
Local Coverage Determination (LCD): Respiratory Assist Devices (L33800) - The Centers for Medicare &
Medicaid Services (CMS) National Coverage Determinations Manual (Internet-Only Manual, Publ. 100-03) in
Chapter 1, Part 4, Section 280.1 stipulates that ventilators (E0465, E0466) are covered for the following
conditions:
"Neuromuscular diseases, thoracic restrictive diseases, and chronic respiratory failure consequent to chronic
obstructive pulmonary disease."
Each of these disease categories are comprised of conditions that can vary from severe and life-threatening to
less serious forms. These ventilator-related disease groups overlap conditions described in this Respiratory
Assist Devices LCD used to determine coverage for bi-level PAP devices. Each of these disease categories are
conditions where the specific presentation of the disease can vary from patient to patient. For conditions such
as these, the specific treatment plan for any individual patient will vary as well. Choice of an appropriate
treatment plan, including the determination to use a ventilator vs. a bi-level PAP device, is made based upon
the specifics of each individual beneficiary's medical condition. In the event of a claim review, there must be
sufficient detailed information in the medical record to justify the treatment selected.
Ventilators fall under the Frequent and Substantial Servicing (FSS) payment category, and payment policy
requirements preclude FSS payment for devices used to deliver continuous and/or intermittent positive airway
pressure, regardless of the illness treated by the device. (Social Security Act 1834(a)(3)(A)) This means that
products currently classified as HCPCS code E0465 or E0466 when used to provide CPAP or bi-level PAP
(with or without backup rate) therapy, regardless of the underlying medical condition, shall not be paid in the
FSS payment category. A ventilator is not eligible for reimbursement for any of the conditions described in this
RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP
(E0470, E0471) mode. Claims for ventilators used to provide CPAP or bi-level CPAP therapy for conditions
described in this RAD policy will be denied as not reasonable and necessary.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.