Noninvasive positive pressure respiratory assistance (NPPRA) therapy is covered for those patients with clinical disorder groups characterized as (I) restrictive thoracic disorders (i.e., progressive neuromuscular diseases or severe thoracic cage abnormalities), (II) severe chronic obstructive pulmonary disease (COPD), (III) central sleep apnea (CSA), or (IV) obstructive sleep apnea (OSA)(E0470 only). See the attachment for specific criteria for these conditions.

Accessories

The following represents the usual maximum amount of accessories expected to be medically necessary:

Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not medically necessary.

Heated and non-heated humidification is eligible for use with a covered respiratory assist device when prescribed by the treating physician to meet the needs of the individual patient.

All equipment and accessories are covered as durable medical equipment and must be prescribed by a physician.

For the purpose of this policy, arterial blood gas, sleep oximetry and polysomnographic studies may not be performed by a DME supplier. A DME supplier is not considered a qualified provider or supplier of these tests for purposes of this policy's coverage and payment guidelines. This prohibition does not extend to the results of studies conducted by hospitals certified to do such tests.

Polysomnographic studies must be performed on stationary equipment.

Services that do not meet the medical necessity guidelines on the policy will be considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Coverage for DME is determined according to individual or group customer benefits.

NOTE:

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

Description

Noninvasive positive pressure respiratory assistance (NPPRA) is the administration of positive air pressure, using a nasal and/or oral mask interface which creates a seal, avoiding the use of more invasive airway access (e.g. tracheostomy). It may sometimes be applied to assist insufficient respiratory efforts in the treatment of conditions that may involve sleep-associated hypoventilation. It is to be distinguished from the invasive ventilation administered via a securely intubated airway, in a patient for whom interruption or failure of ventilatory support would lead to imminent demise of the patient.

A respiratory assist device (RAD) without backup rate (E0470) delivers adjustable, variable levels (within a single respiratory cycle) of positive air pressure by way of tubing and a noninvasive interface (such as a nasal or oral facial mask) to assist spontaneous respiratory efforts and supplement the volume of inspired air into the lungs (i.e., NPPRA).

A respiratory assist device (RAD) with backup rate (E0471) delivers adjustable, variable levels (within a single respiratory cycle) of positive air pressure by way of tubing and a noninvasive interface (such as a nasal or oral facial mask) to assist spontaneous respiratory efforts and supplement the volume of inspired air into the lungs (i.e., NPPRA). In addition, it has a timed backup feature to deliver this air pressure whenever sufficient spontaneous inspiratory efforts fail to occur.

Accessories that are used to deliver air pressure to the patient's nose and/or mouth, and which do not involve an invasive delivery technique such as tracheostomy, are represented by codes A7027, A7028, A7029, A7030, A7031, A7032, A7033, A7034, A7035, A7036, A7037, A7038, A7039, A7044, E0561, and E0562. While these codes have represented accessories used with continuous positive airway pressure devices (CPAP), the same accessories are also used in the application of other forms of NPPRA therapy.

Polysomnography is the continuous and simultaneous monitoring and recording of various physiological and pathophysiological parameters of sleep for 6 or more hours with physician review, interpretation, and report. It must include sleep staging which is defined to include a 1-4 lead electroencephalogram (EEG), and electro-oculogram (EOG), and a submental electromyogram (EMG). It must also include at least the following additional parameters of sleep: airflow, respiratory effort, and oxygen saturation by oximetry.

FIO2 is the fractional concentration of oxygen delivered to the patient for inspiration. For the purpose of this policy, the patient's usual FIO2 refers to the oxygen concentration the patient normally breathes when not undergoing testing to qualify for coverage of NPPRA therapy. That is, if the patient does not normally use supplemental oxygen, their usual FIO2 is that found in room air.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

DME MAC Jurisdiction A L11504, L11528

Region A DMERC 14.30

Community Health Plan of Washington Medical Policy Continuous Positive Airway Pressure (CPAP) and Bi-lvel Positive Airway Pressure (BiPAP), December 3, 2008

Continued Coverage Beyond the Initial Three Months of Therapy

Re-evaluation to establish the medical necessity of continued coverage of these devices must occur within 61 to 90 days from the date the therapy was initiated. Documentation from this evaluation should become part of the patient's medical record. Compliance verification for continued use of Bi-PAP must include the following documentation:

• patient tolerance and compliance with use of equipment for a minimum at 4.5 hours daily and at a minimum rate of 80% of nights (i.e., 24 nights per month), and
• authorized verification of compliance and response by ordering provider.