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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 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 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).
The rules say that The Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations
Manual (CMS Pub. 100-03) in Chapter 1, Part 4, Section 280.1 stipulates that ventilators (E0465, E0466, and
E0467) are covered for the following conditions:
"[N]euromuscular 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 beneficiary to beneficiary. For
conditions such as these, the specific treatment plan for any individual beneficiary 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, E0466, or E0467 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.
General principles of correct coding require that products assigned to a specific HCPCS code only be billed
using the assigned code. Thus, using the HCPCS codes for CPAP (E0601) or bi-level PAP (E0470, E0471)
devices for a ventilator (E0465, E0466, or E0467) used to provide CPAP or bi-level PAP therapy is incorrect
coding. Claims for ventilators billed using the CPAP or bi-level PAP device HCPCS codes will be denied as
incorrect coding.
You can find this information in Medicare's 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.