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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 For an E0470 or an E0471 RAD to be covered, the treating practitioner must fully document 
in the beneficiarys medical record symptoms characteristic of sleep-associated hypoventilation, such as 
daytime hypersomnolence, excessive fatigue, morning headache, cognitive dysfunction, dyspnea. 
 
A RAD (E0470, E0471) is covered for those beneficiaries with one of the following clinical disorders: 
restrictive thoracic disorders (i.e., neuromuscular diseases or severe thoracic cage abnormalities), severe 
chronic obstructive pulmonary disease (COPD), CSA or CompSA, or hypoventilation syndrome, as described 
in the following section. 
 
An E0470 or E0471 device is covered when criteria A  C are met. 
 
    A. There is documentation in the beneficiarys medical record of a neuromuscular disease (for example, 
amyotrophic lateral sclerosis) or a severe thoracic cage abnormality (for example, post-thoracoplasty for TB). 
    B. One of the following: 
           a. An arterial blood gas PaCO2, done while awake and breathing the beneficiarys prescribed FIO2 is 
greater than or equal to 45 mm Hg, or 
           b. Sleep oximetry demonstrates oxygen saturation less than or equal to 88% for greater than or equal to 
5 minutes of nocturnal recording time (minimum recording time of 2 hours), done while breathing the 
beneficiarys prescribed recommended FIO2, or 
           c. For a neuromuscular disease (only), either i or ii, 
               i.Maximal inspiratory pressure is less than 60 cm H20, or 
              ii. Forced vital capacity is less than 50% predicted 
    C. Chronic obstructive pulmonary disease does not contribute significantly to the beneficiarys pulmonary 
limitation. 
 
If all of the above criteria are met, either an E0470 or an E0471 device (based upon the judgment of the treating 
practitioner) will be covered for the first three months of therapy. If all of the above criteria are not met, then 
E0470 or E0471 and related accessories will be denied as not reasonable and necessary.  
 
 
 
 
 The rules say that This section applies to E0470 and E0471 devices initially provided for the scenarios 
addressed in this policy and reimbursed while the beneficiary was in Medicare fee-for-service (FFS). 
If an E0470 or E0471 device is replaced during the 5 year reasonable useful lifetime (RUL) because of loss, 
theft, or irreparable damage due to a specific incident, there is no requirement for a new clinical evaluation or 
testing. 
 
If an E0470 or E0471 device is replaced following the 5 year RUL, there must be an in-person evaluation by 
their treating practitioner that documents that the beneficiary continues to use and benefit from the device. 
There is no requirement for new testing. A new prescription is required. 
 
You can find this rule in the Local Coverage Determination (LCD) Respiratory Assist Devices L33800. 
 
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. The Plan 
contract also says that repairs and replacements of DME are covered due to breakage, wear, or a significant 
change in your physical condition. Repairs and/or replacements will be made when medically necessary and 
covered by Medicare. You can find this information on page 76 of the Plan's 2022 Evidence of Coverage.