Commercial

Respiratory Equipment and Related Supplies (Updated April 16, 2021)​


Policy Impacted

05.00.21x​: Durable Medical Equipment (DME) and Consumable Medical Supplies​

05.00.30m Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices (Independence Administrators)

05.00.48k Durable Medical Equipment (DME) Not Subject to a Rental to Purchase​ Maximum​

05.00.58m Home Oxygen Therapy

07.03.05x: Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies (Independence)



Purpose

The purpose of this News Article is to provide advance notice related to the waiver of certain requirements during the COVID-19 outbreak related to respiratory equipment and related supplies.

This communication addressing the waiver of certain requirements during the COVID-19 outbreak related to respiratory equipment and related supplies is effective from March 6, 2020 and will be reevaluated for continuing applicability on June 30, 2021. ​



Background

There is currently an outbreak of respiratory disease caused by a novel coronavirus, which has now been detected both nationally and internationally. The virus has been named “SARS-CoV-2” and the disease it causes has been named “Coronavirus Disease 2019” (COVID-19). The SARS-CoV-2 virus has demonstrated the capability to rapidly spread, leading to significant impacts on healthcare systems and causing societal disruption. The potential public health threat posed by COVID-19 is high globally. To effectively respond to the COVID-19 outbreak, rapid detection of cases and contacts, appropriate clinical management and infection control, and implementation of community mitigation efforts are critical.



Indications

N/A



Coverage Statement

  • The Company will provide coverage for respiratory equipment (e.g., ventilator, respiratory assist device) and supplies to support ongoing acute care respiratory services in the home setting.
  • Quantity limits for medically necessary respiratory supplies (e.g., nasal cannulas) will be waived during this Public Health Emergency.


REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.


RELATED POLICY BULLETINS

Respiratory equipment and related supplies are addressed in the current versions of the following policy bulletins:

  • 05.00.21: Durable Medical Equipment (DME) and Consumable Medical Supplies

  • 05.00.30: Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices

  • 05.00.48 Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum

  • 05.00.58: Home Oxygen Therapy

  • 07.03.05: Sleep Disorder Testing and Positive Airway Pressure Therapy




Dosing and Administration

N/A



Black Box Warnings and/or Contraindications

N/A



Coding

CODE TYPE
CODE(S) AND NARRATIVE(S)
HCPCS Level II
Ventilator

E0465 Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)

E0466 Home ventilator, any type, used with noninvasive interface, (e.g., mask, chest shell)

E0467 Home ventilator, multi-function respiratory device, also performs any or all of the additional functions of oxygen concentration, drug nebulization, aspiration, and cough stimulation, includes all accessories, components and supplies for all functions


Respiratory assist device / CPAP device

E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0472 Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device)

E0561 Humidifier, nonheated, used with positive airway pressure device

E0562 Humidifier, heated, used with positive airway pressure device

E0601 Continuous airway pressure (CPAP) device


Home Oxygen

E0424 Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing

E0425 Stationary compressed gas system, purchase; includes regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing

E0430 Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing

E0431 Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing

E0433 Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and contents gauge

E0434 Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing

E0435 Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing, and refill adapter

E0439 Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing

E0440 Stationary liquid oxygen system, purchase; includes use of reservoir, contents indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing

E0441 Stationary oxygen contents, gaseous, 1 month's supply = 1 unit

E0442 Stationary oxygen contents, liquid, 1 month's supply = 1 unit

E0443 Portable oxygen contents, gaseous, 1 month's supply = 1 unit

E0444 Portable oxygen contents, liquid, 1 month's supply = 1 unit

E0447 Portable oxygen contents, liquid, 1 month's supply = 1 unit, prescribed amount at rest or nighttime exceeds 4 liters per minute (LPM)

E1390 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate

E1391 Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each

E1392 Portable oxygen concentrator, rental

E1405 Oxygen and water vapor enriching system with heated delivery

E1406 Oxygen and water vapor enriching system without heated delivery

K0738 Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing

S8120 Oxygen contents, gaseous, 1 unit equals 1 cubic foot

S8121 Oxygen contents, liquid, 1 unit equals 1 pound


Supplies

A4604 Tubing with integrated heating element for use with positive airway pressure device

A4608 Transtracheal oxygen catheter, each

A4615 Cannula, nasal

A4616 Tubing (oxygen), per foot

A4617 Mouthpiece

A4619 Face tent

A4620 Variable concentration mask

A7027 Combination oral/nasal mask, used with continuous positive airway pressure device, each

A7028 Oral cushion for combination oral/nasal mask, replacement only, each

A7029 Nasal pillows for combination oral/nasal mask, replacement only, pair

A7030 Full face mask used with positive airway pressure device, each

A7031 Face mask interface, replacement for full face mask, each

A7032 Cushion for use on nasal mask interface, replacement only, each

A7033 Pillow for use on nasal cannula type interface, replacement only, pair

A7034 Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap

A7035 Headgear used with positive airway pressure device

A7036 Chinstrap used with positive airway pressure device

A7037 Tubing used with positive airway pressure device

A7038 Filter, disposable, used with positive airway pressure device

A7039 Filter, nondisposable, used with positive airway pressure device

A7044 Oral interface used with positive airway pressure device, each

A7045 Exhalation port with or without swivel used with accessories for positive airway devices, replacement only

A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, each

A7525 Tracheostomy mask, each

E0455 Oxygen tent, excluding croup or pediatric tents

E0555 Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter

E0580 Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter

E1352 Oxygen accessory, flow regulator capable of positive inspiratory pressure

E1353 Regulator

E1354 Oxygen accessory, wheeled cart for portable cylinder or portable concentrator, any type, replacement only, each

E1355 Stand/rack

E1356 Oxygen accessory, battery pack/cartridge for portable concentrator, any type, replacement only, each

E1357 Oxygen accessory, battery charger for portable concentrator, any type, replacement only, each

E1358 Oxygen accessory, DC power adapter for portable concentrator, any type, replacement only, each





7/17/2020