Appeal type: unknown
Decision: unknown

 
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 Centers for Medicare and Medicaid Services, Internet 
Only Manual, Publication 100-03, 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 persons 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). 
 
High frequency chest wall oscillation devices (HFCWO) (E0483) are covered for beneficiaries who meet: 
 
    Criterion 1, 2, or 3, and 
 
    Criterion 4 
 
        There is a diagnosis of cystic fibrosis (refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses). 
 
        There is a diagnosis of bronchiectasis (refer to the ICD-10 code list in the LCD-related Policy Article for 
applicable diagnoses) which has been confirmed by a high resolution, spiral, or standard CT scan and which is 
characterized by: 
 
                Daily productive cough for at least 6 continuous months; or 
 
                Frequent (i.e., more than 2/year) exacerbations requiring antibiotic therapy. 
 
        Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed diagnosis of bronchiectasis do not meet this criterion. 
 
        The beneficiary has one of the following neuromuscular disease diagnoses (refer to the ICD-10 code list in 
the LCD-related Policy Article for applicable diagnoses): 
        Post-polio 
        Acid maltase deficiency 
        Anterior horn cell diseases 
        Multiple sclerosis 
        Quadriplegia 
        Hereditary muscular dystrophy 
        Myotonic disorders 
        Other myopathies 
        Paralysis of the diaphragm 
 
        There must be well-documented failure of standard treatments to adequately mobilize retained secretions. 
 
If all of the criteria are not met, the claim will be denied as not reasonable and necessary. 
 
It is not reasonable and necessary for a beneficiary to use both a HFCWO device and a mechanical in-
exsufflation device (E0482). 
 
Replacement supplies, A7025 and A7026, used with beneficiary owned equipment, are covered if the 
beneficiary meets the criteria listed above for the base device, E0483. If these criteria are not met claims will be 
denied as not reasonable and necessary. 
 
You can find this information in the Local Coverage Determination (LCD) High Frequency Chest Wall 
Oscillation Devices L33785. 
 
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.