The guidelines below include the following topics. Click on a topic to go directly to that section.

• General Coverage Criteria
• Initial Coverage for New Set-Up (First 3 Months)
• Continued Coverage Beyond the First 3 Months of Therapy
• Accessories
• References (Local Coverage Determination and Policy Article)

General Coverage Criteria

Covered if the beneficiary is diagnosed with obstructive sleep apnea (OSA). Coverage for this equipment is diagnosis driven. Please refer to the Policy Article in the References section below for associated ICD-10 diagnosis codes.

The PAP policy applies to both a Continuous Positive Airway Pressure (CPAP) device as well as a bi-level device when used to treat OSA. The diagnosis of OSA must be documented by either an attended, facility-based polysomnogram (sleep study) or an in-patient hospital-based or home-based sleep test (HST). The sleep study must be signed by the interpreting practitioner.

Initial Coverage for New Set-Up (First 3 Months)

Continuous Positive Airway Pressure (CPAP)

A single level continuous positive airway pressure (CPAP) device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A – C are met.

1. The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to assess the beneficiary for obstructive sleep apnea.  The initial evaluation should document pertinent information about the beneficiary’s history of sleep-related issues and should address the following elements but may include other details. Each element would not have to be addressed in every evaluation.
   History
   1. Signs and symptoms of sleep disordered breathing including snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches
   2. Duration of symptoms
   3. Validated sleep hygiene inventory such as the Epworth Sleepiness Scale
   Physical Exam
   1. Focused cardiopulmonary and upper airway system evaluation
   2. Neck circumference
   3. Body mass index (BMI)
2. The beneficiary has a sleep test that meets either of the following criteria (1 or 2):
   1. The Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) ≥ 15 events per hour with a minimum of 30 events; or
   2. AHI or RDI ≥ 5 and ≤ 14 events per hour with a minimum of 10 events and documentation of:
      1. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia: or
      2. Hypertension, ischemic heart disease, or history of stroke.
   If the AHI or RDI is calculated based on less than 2 hours of sleep or recording time, the total number of recorded events used to calculate the AHI or RDI, respectively, must be at least the number of events that would have been required in a 2 hour period (i.e., must reach greater than or equal to 30 events without symptoms or greater than or equal to 10 events with symptoms).
3. The beneficiary and/or his/her caregiver has/have received instruction from the supplier of the PAP device and accessories in the proper use and care of the equipment.

Bi-Level Device

A bi-level device without backup rate is covered for those beneficiaries with OSA who meet criteria A – C above, in addition to criterion D:
D. A single level positive airway pressure device has been tried and proven ineffective, based on a therapeutic trial conducted in either a facility or in a home setting. Ineffective is defined as documented failure to meet therapeutic goals using a PAP device during the titration portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings). The treating practitioner must document that an appropriate interface has been properly fit and the beneficiary uses it without difficulty, the CPAP pressure setting prevented the beneficiary from tolerating the therapy and lower pressure settings of the CPAP tried but failed to:
1. Adequately control the symptoms of OSA, or
2. Improve sleep quality, or
3. Reduce the AHI/RDI to acceptable levels.

Continued Coverage Beyond the First 3 Months of Therapy

No sooner than the 31st day but no later than the 91st day after initiating therapy, the treating practitioner must conduct a face-to-face clinical re-evaluation and document that the beneficiary is benefiting from PAP therapy.
Documentation of clinical benefit is demonstrated by:

1. Face-to-face clinical re-evaluation by the treating practitioner (between the 31st and 91st day) with documentation that symptoms of obstructive sleep apnea are improved, and the beneficiary is benefiting from PAP therapy; and
2. Objective evidence of adherence to use of the PAP device. Adherence to therapy is defined as use of PAP at least 4 hours per night on 70% of nights during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. This can be accomplished either through direct download or visual inspection of adherence information.

Beneficiaries who fail the initial 12 week trial are eligible to re-qualify for a PAP device but must have both:

1. In-person clinical re-evaluation by the treating practitioner to determine the etiology of the failure to respond to PAP therapy; and
2. Repeat sleep test in a facility-based setting (Type 1 study). This may be a repeat diagnostic, titration or split-night study.

If a PAP device was used for more than 3 months and the beneficiary was then switched to a bi-level, the clinical re-evaluation must occur between the 31st and 91st day following the initiation of the bi-level. There would also need to be documentation of adherence to therapy during the 3 month trial with the bilevel.

Accessories

Accessories used with a PAP device are covered when the coverage criteria for the device are met. Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not reasonable and necessary.

References

• Local Coverage Determination - Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea
• A52467 - Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea - Policy Article 

The guidelines below include the following topics. Click on a topic to go directly to that section.

• Coverage Criteria
• Supplies
• References (Local Coverage Determination and Policy Article)

Coverage Criteria

1. There is a diagnosis of cystic fibrosis; or
2. There is a diagnosis of bronchiectasis 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.
     Note: Chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the absence of a confirmed diagnosis of bronchiectasis does not meet this criterion.
     or
3. The beneficiary has one of the following neuromuscular disease diagnoses*
   • Post-polio
   • Anterior horn cell diseases
   • Acid maltase deficiency
   • Quadriplegia
   • Paralysis of the diaphragm
   • Myotonic disorders
   • Multiple sclerosis
   • Hereditary muscular dystrophy
   • Other myopathies
     * Please refer to the Policy Article in the References section below for a list of additional ICD-10 diagnoses codes.
     and
4. There must be well-documented failure of standard treatments to adequately mobilize retained secretions.
   Note: There must be information in the beneficiary’s medical record that describes in detail the underlying medical condition(s) that cause the accumulation of pulmonary secretions, the treatment interventions (for example, chest physiotherapy, postural drainage, medications used, mechanical modalities such as in-exsufflation devices (not all inclusive)) and the effectiveness of the treatment.

It is not reasonable and necessary for a beneficiary to use both a HFCWO device (E0483) and a mechanical in-exsufflation device (E0482).

Supplies

• Supplies used in conjunction with an HFCWO are included in Medicare’s monthly reimbursement for the rental of the HFCWO and are not separately billable.
• Replacement supplies (A7025 and A7026), used with beneficiary owned equipment, are covered if the beneficiary meets the criteria listed for the base device.

References

• Local Coverage Determination - High Frequency Chest Wall Oscillation Device
• A52494 - High Frequency Chest Wall Oscillation Devices - Policy Article

The guidelines below include the following topics. Click on a topic to go directly to that section.

• Coverage Criteria

• Accessories

• References (Local Coverage Determination and Policy Article)

Coverage Criteria

Covered if the beneficiary’s medical record establishes medical necessity due to one or more of the following reasons:

1. The beneficiary’s medical condition requires positioning of the body in ways not feasible in an ordinary bed. Elevation of the head/upper body less than 30 degrees does not usually require the use of a hospital bed, or
2. The beneficiary requires positioning of the body in ways not feasible in an ordinary bed in order to alleviate pain, or
3. The beneficiary requires the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration, or
4. The beneficiary requires traction equipment that cannot be affixed to or used on an ordinary bed.

Variable Height Feature may be covered when the beneficiary requires a bed height different than a fixed height bed to permit transfers to chair, wheelchair or standing position if hospital bed coverage requirements are met and the medical record establishes the medical necessity for a variable height hospital bed.

Semi-Electric Bed (electric powered adjustments to raise and lower the head and foot) may be covered when the beneficiary’s condition requires frequent changes in body position and/or the beneficiary may need immediate changes in body position.

Full-Electric Bed is not covered (the full-electric bed height adjustment feature is a non-covered convenience feature; therefore, a full-electric bed is not covered).

Heavy Duty Bed is covered if hospital bed coverage requirements are met and the beneficiary’s weight is more than 350 pounds but does not exceed 600 pounds.

Extra Heavy-Duty Bed is covered if hospital bed coverage requirements are met and the beneficiary’s weight exceeds 600 pounds.

Accessories

Refer to the Accessories section in the Local Coverage Determination in the References section below for information regarding hospital bed accessories and coverage requirements.

References

• Local Coverage Determination - Hospital Beds and Accessories
• A52508 - Hospital Beds And Accessories - Policy Article 

 Coverage Criteria

Small Volume Nebulizer and Related Compressor are covered when it is reasonable and necessary to administer the following FDA-approved inhalation solutions listed below:

1. It is reasonable and necessary to administer albuterol, arformoterol, budesonide, cromolyn, formoterol, ipratropium, levalbuterol, metaproterenol, or revefenacin for the management of obstructive pulmonary disease, or

2. It is reasonable and necessary to administer dornase alpha to a beneficiary with cystic fibrosis, or

3. It is reasonable and necessary to administer tobramycin to a beneficiary with cystic fibrosis or bronchiectasis, or

4. It is reasonable and necessary to administer pentamidine to a beneficiary with HIV, pneumocystosis, or complications of organ transplants, or

5. It is reasonable and necessary to administer acetylcysteine for persistent thick or tenacious pulmonary secretions.

   Coverage for this equipment is diagnosis driven. Please refer to the Policy Article in the Reference section below for associated ICD-10 diagnosis codes.

Use of compounded inhalation solutions will be denied as not reasonable and necessary.  If none of the drugs used with a nebulizer are covered, the nebulizer, compressor and its accessories/supplies will be denied as not reasonable and necessary.

Large Volume Nebulizer, Related Compressor, and Water or Saline are considered for coverage when it is reasonable and necessary to deliver humidity to a beneficiary with thick, tenacious secretions, who has cystic fibrosis, bronchiectasis, a tracheostomy, or a tracheobronchial stent.

Compressor and Filtered Nebulizer are also covered when it is reasonable and necessary to administer pentamidine to beneficiaries with HIV, pneumocystosis, or complications of organ transplants.

Small Volume Ultrasonic Nebulizer and Related Accessories are considered for coverage when it is reasonable and necessary to administer treprostinil inhalation solution to beneficiaries with pulmonary hypertension only. Claims for use with other inhalation solutions will be denied as not reasonable and necessary.

Controlled Dose Inhalation Drug Delivery System is considered for coverage when it is reasonable and necessary to administer  iloprost to beneficiaries with pulmonary hypertension only. Claims for use with other inhalation solutions will be denied as not reasonable and necessary.

Nebulizer Inhalation Drugs

Inhalation drugs are covered when administered via a prescribed nebulizer.  

Treprostinil Inhalation Solution and Iloprost are considered for coverage when all  the following criteria 1–3 are met:

1. The beneficiary has a diagnosis of pulmonary artery hypertension; and
2. The pulmonary hypertension is not secondary to pulmonary venous hypertension or disorders of the respiratory system; and
3. The beneficiary has primary pulmonary hypertension or pulmonary hypertension which is secondary to one of the following conditions: connective tissue disease, human immunodeficiency virus (HIV) infection, cirrhosis, anorexigens or congenital left to right shunts. If these conditions are present, the following criteria (a–d) must be met:
   1. The pulmonary hypertension has progressed despite maximal medical and/or surgical treatment of the identified condition, and
   2. The mean pulmonary artery pressure is > 25 mm Hg at rest or > 30 mm Hg with exertion, and
   3. The beneficiary has significant symptoms from the pulmonary hypertension, and
   4. Treatment with oral calcium channel blocking agents has been tried and failed or has been considered and ruled out.
   
   Treprostinil inhalation solution may also be considered if criterion 4 alone is met:
4. The beneficiary has a diagnosis of pulmonary hypertension associated with interstitial lung disease and all the following criteria (a-e) are met:
   1. The presence of interstitial lung disease has been confirmed by a high-resolution CT scan of the chest, and
   2. The mean pulmonary artery pressure is ≥25 mm Hg, and
   3. The pulmonary capillary wedge pressure or left ventricular end-diastolic pressure is <= 15 mm Hg, and
   4. The pulmonary vascular resistance is ≥ 3 Wood Units at rest, and
   5. The beneficiary has significant symptoms of pulmonary hypertension.

* Special Drug Coverage

When albuterol, levalbuterol, or metaproterenol are prescribed as rescue/supplemental medication for beneficiaries who are taking formoterol or arformoterol, the maximum milligrams/month that are reasonably billed are:

Nebulizer Accessories

Accessories are separately payable if the related aerosol compressor and the individual accessories are reasonable and necessary.

References

• Local Coverage Determination - Nebulizers
• A52466 - Nebulizers - Policy Article 

The guidelines below include the following topics. Click on a topic to go directly to that section.

• Initial Coverage Requirements
• Continued Coverage Criteria
• When Coverage Ends
• Policy Specific Documentation Requirements
• Supplies
• References (Local Coverage Determination and Policy Article)

Initial Coverage Requirements

Covered when either criterion A or B is met:
A. Ulcers and wounds in the home setting:
The beneficiary has a chronic Stage III or Stage IV pressure ulcer, neuropathic (for example, diabetic) ulcer, venous or arterial insufficiency ulcer, or a chronic (being present for at least 30 days) ulcer of mixed etiology. A complete wound therapy program described by criterion 1 and criteria 2, 3 or 4, as applicable depending on the type of wound, must have been tried or considered and ruled out prior to the application of NPWT

1. For all ulcers or wounds, the following components of a wound therapy program must include a minimum of all of the following general measures, which should either be addressed, applied, or considered and ruled out prior to application of NPWT:
   1. Documentation in the beneficiary’s medical record of evaluation, care, and wound measurements by a licensed medical professional, and
   2. Application of dressings to maintain a moist wound environment, and
   3. Debridement of necrotic tissue if present, and
   4. Evaluation of and provision for adequate nutritional status.
2. For Stage III or Stage IV pressure ulcers:
   1. The beneficiary has been appropriately turned and positioned, and
   2. The beneficiary has used a Group 2 or 3 support surface for pressure ulcers on the posterior trunk or pelvis, and
   3. The beneficiary moisture and incontinence have been appropriately managed.
3. For neuropathic (for example, diabetic) ulcers:
   1. The beneficiary has been on a comprehensive diabetic management program, and
   2. Reduction in pressure on a foot ulcer has been accomplished with appropriate modalities.
4. For venous insufficiency ulcers:
   1. Compression bandages and/or garments have been consistently applied, and
   2. Leg elevation and ambulation have been encouraged.

B. Ulcers and wounds encountered in an in-patient setting:
In either situations B-1 or B-2, NPWT will be covered when treatment continuation is ordered beyond discharge to the home setting. A DMEPOS supplier cannot bill Medicare Part B for the time the treatment is used in an in-patient setting.

1. An ulcer or wound, described under A above, is encountered in the in-patient setting and, after wound treatments described under A-1 through A-4 have been tried or considered and ruled out, NPWT is initiated because it is considered to be the best available treatment option in the judgment of the treating practitioner, or
2. The beneficiary has complications of a surgically created wound (for example, dehiscence) or a traumatic wound (for example, pre-operative flap or graft) where there is documentation of the medical necessity for accelerated formation of granulation tissue which cannot be achieved by other available topical wound treatments (for example, other conditions of the beneficiary that will not allow for healing times achievable with other topical wound treatments).

If criterion A or B is not met, the NPWT pump and supplies will be denied as not reasonable and necessary.

Additionally, an NPWT pump and supplies will be denied at any time as not reasonable and necessary if one or more of the following are present:

• The presence in the wound of necrotic tissue with eschar, if debridement is not attempted, or
• Untreated osteomyelitis within the vicinity of the wound, or
• Cancer present in the wound, or
• The presence of a fistula to an organ or body cavity within the vicinity of the wound

Continued Coverage Criteria

C. For wounds and ulcers described under criterion A or B, once placed on an NPWT pump and supplies, in order for coverage to continue, a licensed medical professional must do the following:

1. On a regular basis,
   1. Directly assess the wound(s) being treated with the NPWT pump, and
   2. Supervise or directly perform the NPWT dressing changes, and
2. On at least a monthly basis, document changes in the wound’s dimensions and characteristics, amount of exudate and progress of healing.
   If criteria C-1 and C-2 are not fulfilled, continued coverage of the NPWT pump and supplies will be denied as not reasonable and necessary.

When Coverage Ends

For wounds and ulcers described under criterion A or B, an NPWT pump and supplies will be denied as not reasonable and necessary with any of the following, whichever occurs earliest:

1. Criteria C-1 and C-2 cease to occur.
2. In the judgment of the treating practitioner, adequate wound healing has occurred to the degree that NPWT may be discontinued.
3. Any measurable degree of wound healing has failed to occur over the prior month. Wound healing is defined as improvement occurring in either surface area (length times width) or depth of the wound.
4. Four months (including the time NPWT was applied in an in-patient setting prior to discharge to the home) have elapsed using an NPWT pump in the treatment of the most recent wound. To accurately account for the duration of treatment, the date of placement/initiation of NPWT pump while inpatient must be clearly documented.
5. Once equipment or supplies are no longer being used for the beneficiary whether or not by the treating practitioner’s order.

Policy Specific Documentation Requirements

Documentation of the history, previous treatment regimens, and current wound management for which an NPWT pump is being billed must be present in the beneficiary’s medical record and be available upon request. This documentation must include such elements as length of sessions of use, dressing types and frequency of change, and changes in wound conditions, including precise measurements (length, width, and depth), quantity of exudates, presence of granulation and necrotic tissue and concurrent measures being addressed relevant to wound therapy (debridement, nutritional concerns, support surfaces in use, positioning, incontinence control, etc.).

The medical record must include a statement from the treating practitioner describing the initial condition of the wound (including measurements) and the efforts to address all aspects of wound care (listed in A-1 through A-4). For each subsequent month, the medical record must include updated wound measurements and what changes are being applied to effect wound healing.

Supplies

Coverage is provided up to a maximum of 15 dressing kits (A6550) per wound per month. Coverage is provided up to a maximum of 10 canister sets (A7000) per month unless there is documentation evidencing a large volume of drainage (greater than 90 ml of exudate per day).  For high volume exudative wounds, a stationary pump with the largest capacity canister must be used.

References

• Local Coverage Determination - Negative Pressure Wound Therapy Pumps
• A52511 - Negative Pressure Wound Therapy Pumps - Policy Article

The guidelines below include the following topics. Click on a topic to go directly to that section.

• General Coverage Criteria
• Oxygen Coverage Groups
• Qualifying Testing
• Concurrent Use of Oxygen with PAP Therapy
• Recertification and Re-evaluation
• High Liter Flow Oxygen
• Portable Oxygen
• References (Oxygen LCD and Policy Article)

General Coverage Criteria

Covered if the treating practitioner has ordered and evaluated the results of a qualifying blood gas study performed at the time of need and the beneficiary’s blood gas studies meet one of the criteria below; and the qualifying blood gas study was performed by a treating practitioner or by a qualified provider or supplier of laboratory services; and the provision of oxygen and oxygen equipment in the home setting will improve the beneficiary’s condition.

Time of need is defined as during the patient’s illness when the presumption is that the provision of oxygen will improve the patient’s condition in the home setting. For an inpatient hospital patient anticipated to require oxygen upon going home, the time of need would be within 2 days of discharge.

Documentation for initial coverage requires information in the medical record showing:

• Evidence of qualifying test results at the time of need; and
• Evidence of an evaluation of the qualifying test results by a treating practitioner
• The above information should be documented in the beneficiary’s medical record.
  

Oxygen Coverage Groups

There are four basic groups of values for ABGs and O2 saturation that will determine coverage.

Group I Criteria

Include any of the following:    

1. An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88% taken at rest (awake), or
2. An arterial PO2 at or below 55 mm Hg, or an arterial oxygen saturation at or below 88%, taken during sleep for a beneficiary who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89% while awake, or
3. A decrease in arterial PO2 more than 10 mm Hg, or a decrease in arterial oxygen saturation more than 5% from baseline saturation, taken during sleep and associated with symptoms or signs reasonably attributable to hypoxemia (e.g., cor pulmonale, “P” pulmonale on EKG, documented pulmonary hypertension and erythrocytosis), or
4. An arterial PO2 at or below 55 mm Hg or an arterial oxygen saturation at or below 88%, taken during exercise for a beneficiary who demonstrates an arterial PO2 at or above 56 mm Hg or an arterial oxygen saturation at or above 89% during the day while at rest. In this case, oxygen is provided for during exercise if it is documented that the use of oxygen improves the hypoxemia that was demonstrated during exercise when the beneficiary was breathing room air.

Note: Coverage for beneficiaries meeting Group I criteria is limited to 12 months or the treating practitioner specified length of need, whichever is shorter.

Group II Criteria

Include the presence of:

1. An arterial PO2 of 56 –59 mm Hg or an arterial blood oxygen saturation of 89% at rest (awake), during sleep, or during exercise (as described under Group I criteria), and
2. Any of the following:
   1. Dependent edema suggesting congestive heart failure, or
   2. Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or “P” pulmonale on EKG (P wave greater than 3 mm in standard leads II, III, or AVF), or
   3. Erythrocythemia with a hematocrit greater than 56%.

Note: Coverage for beneficiaries meeting Group II criteria is limited to 3 months or the treating practitioner specified length of need, whichever is shorter.

Group III Criteria

1. Absence of hypoxemia defined in Group I and Group II above; and
2. A medical condition with distinct physiologic, cognitive, and/or functional symptoms documented in high-quality, peer-reviewed literature to be improved by oxygen therapy, such as cluster headaches (not all inclusive).
   

Group IV Criteria

Oxygen therapy and oxygen equipment will also be denied as not reasonable and necessary if any of the following conditions are present:

1. Angina pectoris in the absence of hypoxemia. This condition is generally not the result of a low oxygen level in the blood and there are other preferred treatments; or
2. Dyspnea without cor pulmonale or evidence of hypoxemia; or
3. Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities but in the absence of systemic hypoxemia. There is no evidence that increased PO2 will improve the oxygenation of tissues with impaired circulation; or
4. Terminal illnesses that do not affect the ability to breathe.
   

Qualifying Testing

Qualifying test during exercise: In instances where a beneficiary qualifies for oxygen based on a test conducted during exercise, the following tests must be obtained in order for coverage criteria to be met:

1. Testing at rest without oxygen: A test taken while the beneficiary is at rest breathing room air, and
2. Testing during exercise without oxygen: During exercise, while the beneficiary continues to breathe room air, and
3. Testing during exercise with oxygen applied (to demonstrate the improvement of the hypoxemia) is required: A test taken with the beneficiary receiving supplemental oxygen, which shows an improvement in the hypoxemia that was demonstrated during exercise when the beneficiary was breathing room air.

All three tests must be performed within the same testing session. Exercise testing must be performed in-person by a treating practitioner or other medical professional qualified to conduct exercise oximetry testing. Unsupervised or remotely supervised home exercise testing does not qualify as a valid test for purposes of Medicare reimbursement of home oxygen and oxygen equipment.

Note: Oximetry obtained after exercise while resting, sometimes referred to as “recovery” testing, is not part of the three required test elements and is not valid for determining eligibility for oxygen coverage.

Qualifying test conducted during sleep: In instances where a beneficiary qualifies for oxygen based on a test conducted during sleep, the following tests must be obtained in order for coverage criteria to be met:

1. During sleep, the beneficiary’s arterial PO2 is <55 mm Hg or the O2 SAT <88%, or
2. During sleep, there is a decrease in the arterial PO2 of more than 10 mm Hg or a decrease in the O2 SAT of more than 5% and the beneficiary suffers with symptoms (e.g., impairment of cognitive processes and nocturnal restlessness or insomnia) or signs (cor pulmonale, “P” pulmonale on EKG, pulmonary hypertension, erythrocytosis) reasonably attributable to hypoxemia.

Note: Overnight oximetry does not include oximetry obtained during polysomnography or other sleep testing for sleep apnea, regardless of the location the testing was performed.
Beneficiaries who meet coverage criteria during sleep do not qualify for payment of portable oxygen equipment.

Concurrent Use of Oxygen with PAP Therapy

Some beneficiaries may require the simultaneous use of home oxygen therapy and oxygen equipment with a PAP device. To be considered for simultaneous coverage, all requirements in both the Oxygen and Oxygen Equipment and Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea LCDs must be met.

For beneficiaries with Obstructive Sleep Apnea (OSA), this means that the OSA must be sufficiently treated such that the underlying condition resulting in hypoxemia is unmasked. This must be demonstrated before oxygen saturation results obtained during polysomnography are considered qualifying for oxygen therapy. A qualifying oxygen saturation test may only occur during a titration polysomnographic study (either split night or stand-alone) if all of the following criteria are met:

1. The titration is conducted over a minimum of two (2) hours; and
2. During titration:
   1. The AHI/RDI is reduced to less than or equal to an average of ten (10) events per hour; or
   2. If the initial AHI/RDI was less than an average of ten (10) events per hour, the titration demonstrates further reduction in the AHI/RDI; and
3. Nocturnal oximetry conducted for the purpose for oxygen reimbursement qualification may only be performed after optimal PAP settings have been determined and the beneficiary is using the PAP device at those settings; and
4. The nocturnal oximetry conducted during the PSG demonstrates an oxygen saturation ≤ 88%.

Beneficiaries who qualify for oxygen therapy based on testing conducted only during the course of a sleep test are eligible only for reimbursement of stationary equipment.

Recertification and Re-Evaluation

• For beneficiaries initially meeting Group I criteria, there is no formal requirement for a re-evaluation but practitioners should ensure the oxygen remains reasonable and necessary.
• Beneficiaries initially meeting Group II criteria must be seen and re-evaluated by the treating practitioner and retested between the 61st and 90th day after the initiation of therapy. A new SWO is required at that time.
• Beneficiaries initially meeting Group III criteria must be seen and re-evaluated by the treating practitioner and retested between the 61st and 90th after initiation of therapy. A new SWO is required.

Note: If oxygen coverage is approved, any equipment and supplies necessary to the beneficiary’s use of covered home oxygen therapy, such as regulators (flowmeters), humidifiers and face masks, are also covered. Back-up oxygen tanks are not covered. Supplies are not separately reimbursable unless the equipment is owned by the beneficiary.

High Liter Flow Oxygen

Covered if basic oxygen coverage criteria have been met, a higher allowance for a stationary system for a flow rate of greater than 4 liters per minute (LPM) will be paid only if a blood gas study performed while the beneficiary is on 4 or more LPM meets Group I or II criteria. If a flow rate greater than 4 LPM is billed and the coverage criterion for the higher allowance is not met, payment will be made at the standard fee schedule rate.

Portable Oxygen

Covered if the beneficiary is mobile within the home and the qualifying blood gas study was performed while at rest (awake) or during exercise. If the only qualifying blood gas study was performed during sleep, portable oxygen will be denied as not medically necessary. 

References

• Local Coverage Determination - Oxygen and Oxygen Equipment
• A52514 - Oxygen and Oxygen Equipment - Policy Article 
  

The guidelines below include the following topics.  Click on a topic to go directly to that section.

• Coverage Criteria
• Documentation Requirements
• Accessories
• References (Local Coverage Determination and Policy Article)

Coverage Criteria

A RAD (E0470, E0471) is covered for the first three months of therapy for beneficiaries with one of the following clinical disorders: I. Restrictive thoracic disorders (i.e., neuromuscular diseases or severe thoracic cage abnormalities); II. Severe chronic obstructive pulmonary disease (COPD); III. Central sleep apnea (CSA) or complex sleep apnea (Comp SA); or IV. Hypoventilation syndrome; and who also meet the following criteria:

I. Restrictive Thoracic Disorders

An E0470 or E0471 device is covered when criteria A – C are met:

1. There is documentation in the beneficiary’s medical record of a neuromuscular disease (for example, amyotrophic lateral sclerosis) or a severe thoracic cage abnormality (for example, post-thoracoplasty for TB).
2. One of the following:
   1. An arterial blood gas PaCO2, done while awake and breathing the beneficiary’s prescribed FIO2 is ≥ 45 mm Hg; or
   2. Sleep oximetry demonstrates oxygen saturation ≤ 88% for ≥ 5 minutes of nocturnal recording time (minimum recording time of 2 hours), done while breathing the beneficiary’s prescribed recommended FIO2; or
   3. For a neuromuscular disease (only), either i or ii:
      1. Maximal inspiratory pressure is < 60 cm H2O; or
      2. Forced vital capacity is < 50% predicted.
3. Chronic obstructive pulmonary disease does not contribute significantly to the beneficiary’s 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.

II. Severe COPD

An E0470 device is covered if criteria A – C are met:

1. An arterial blood gas PaCO2, done while awake and breathing the beneficiary’s prescribed FIO2, is ≥ 52 mm Hg.
2. Sleep oximetry demonstrates oxygen saturation ≤ 88% for ≥ a cumulative 5 minutes of nocturnal recording time (minimum recording time of 2 hours), done while breathing oxygen at 2 LPM or the beneficiary’s prescribed FIO2 (whichever is higher).
3. Prior to initiating therapy, sleep apnea and treatment with a continuous positive airway pressure device (CPAP) has been considered and ruled out. (Note: Formal sleep testing is not required if there is sufficient information in the medical record to demonstrate that the beneficiary does not suffer from some form of sleep apnea (Obstructive Sleep Apnea [OSA], CSA and/or Comp SA) as the predominant cause of awake hypercapnia or nocturnal arterial oxygen desaturation).
   If all of the above criteria for beneficiaries with COPD are met, an E0470 device will be covered for the first three months of therapy.

An E0471 device will be covered for a beneficiary with COPD in either of the two situations below, depending on the testing performed to demonstrate the need.

Situation 1: For Group II beneficiaries (COPD) who qualified for an E0470 device, an E0471 started any time after a period of initial use of an E0470 device is covered if both criteria a and b are met.

1. An arterial blood gas PaCO2, done while awake and breathing the beneficiary’s prescribed FIO2, shows that the beneficiary’s PaCO2 worsens ≥ 7 mm Hg compared to the original result from criterion A,(above).
2. A facility-based PSG demonstrates oxygen saturation ≤ 88% for ≥ a cumulative 5 minutes of nocturnal recording time (minimum recording time of 2 hours) while using an E0470 device that is not caused by obstructive upper airway events — i.e., AHI < 5. (Refer to the Positive Airway Pressure Devices LCD for information about E0470 coverage for obstructive sleep apnea).

Situation 2: For Group II beneficiaries (COPD) who qualified for an E0470 device, an E0471 device will be covered if, at a time no sooner than 61 days after initial issue of the E0470 device, both of the following criteria A and B are met:

1. An arterial blood gas PaCO2 is done while awake and breathing the beneficiary’s prescribed FIO2, still remains ≥ 52 mm Hg.
2. Sleep oximetry while breathing with the E0470 device, demonstrates oxygen saturation ≤ 88% for ≥ a cumulative 5 minutes of nocturnal recording time (minimum recording time of 2 hours), done while breathing oxygen at 2 LPM or the beneficiary’s prescribed FIO2 (whichever is higher).

III. Central Sleep Apnea or Complex Sleep Apnea

An E0470 or E0471 device is covered when, prior to initiating therapy, a complete facility-based, attended PSG is performed documenting the following: (A and B)

1. The diagnosis of central sleep apnea (CSA) or complex sleep apnea (Comp SA); and
2. Significant improvement of the sleep-associated hypoventilation with the use of an E0470 or E0471 device on the settings that will be prescribed for initial use at home, while breathing the beneficiary’s prescribed FIO2.
   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 beneficiaries with documented CSA or Comp SA for the first three months of therapy.

IV. Hypoventilation Syndrome

An E0470 device is covered if both criteria A and B and either criterion C or D are met.

1. An initial arterial blood gas PaCO2, done while awake and breathing the beneficiary’s prescribed FIO2, is ≥ 45 mm Hg; and
2. Spirometry shows an FEV1/FVC ≥ 70%. (Refer to II. SEVERE COPD (above) for information about device coverage for beneficiaries with FEV1/ FVC < 70%.)
3. An arterial blood gas PaCO2, done during sleep or immediately upon awakening, and breathing the beneficiary’s prescribed FIO2, shows the beneficiary’s PaCO2 worsened ≥ 7 mm Hg compared to the original result in criterion 1 (above); or
4. A facility-based PSG or HST demonstrates oxygen saturation ≤ 88% for ≥ 5 minutes of nocturnal recording time (minimum recording time of 2 hours) that is not caused by obstructive upper airway events — i.e., AHI < 5. (Refer to the Positive Airway Pressure Devices LCD for information about E0470 coverage for obstructive sleep apnea.)

An E0471 device is covered for a beneficiary with hypoventilation syndrome if both criteria A, B, and either criterion C or D are met:

1. A covered E0470 device is being used; and
2. Spirometry shows an FEV1/FVC ≥ 70%. (Refer to II. SEVERE COPD (above) for information about device coverage for beneficiaries with FEV1/ FVC < 70%.)
3. An arterial blood gas PaCO2, done while awake and breathing the beneficiary’s prescribed FIO2, shows that the beneficiary’s PaCO2 worsens
   ≥ 7 mm Hg compared to the ABG result performed to qualify the beneficiary for the E0470 device; or
4. A facility-based PSG or HST demonstrates oxygen saturation ≤ 88% for ≥ 5 minutes of nocturnal recording time (minimum recording time of 2 hours) that is not caused by obstructive upper airway events — i.e., AHI < 5 while using an E0470 device. (Refer to the Positive Airway Pressure Devices LCD for information about E0470 coverage for obstructive sleep apnea.)

Documentation Requirements

Beneficiaries covered for the first three months of an E0470 or an E0471 device must be re-evaluated to establish the medical necessity of continued coverage by Medicare beyond the first three months. While the beneficiary may certainly need to be evaluated at earlier intervals after this therapy is initiated, the re-evaluation upon which Medicare will base a decision to continue coverage beyond this time must occur no sooner than 61 days after initiating therapy by the treating practitioner.

There must be documentation in the beneficiary’s medical record about the progress of relevant symptoms and beneficiary usage of the device up to that time. Failure of the beneficiary to be consistently using the E0470 or E0471 device for an average of 4 hours per 24 hour period by the time of the re-evaluation (on or after 61 days after initiation of therapy) would represent non-compliant utilization for the intended purposes and expectations of benefit of this therapy.

Note: A DME supplier is NOT considered a qualified supplier of any testing referenced above.

Accessories

Accessories used with a RAD device are covered when the coverage criteria for the device are met.  Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not reasonable and necessary.

References

• Local Coverage Determination - Respiratory Assist Devices
• A52517 - Respiratory Assist Devices - Policy Article

The guidelines below include the following topics.  Click on a topic to go directly to that section.

• Coverage Criteria
• Second Ventilator
• References (Local Coverage Determination and Policy Article)

Coverage Criteria

Invasive Ventilator (via tracheostomy) and Non-Invasive Ventilator (NIV)

Covered for treatment of neuromuscular diseases, restrictive thoracic diseases and chronic respiratory failure consequent to chronic obstructive pulmonary disease. Each of these disease categories are conditions where the specific presentation of the disease can vary from patient to patient. For conditions such as these, the specific treatment plan for any individual patient will vary as well. 

Note:  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 sufficiently detailed information in the medical record to support the treatment selected. A ventilator is not eligible for reimbursement for any of the conditions described in the RAD LCD even though the ventilator equipment may have the capability of operating in a bi-level PAP (E0470, E0471) mode.

A ventilator would not be considered reasonable and necessary for the treatment of Obstructive Sleep Apnea (OSA). Claims for ventilators used for the treatment of conditions described under Positive Airway Pressure (PAP) Device or Respiratory Assist Device (RAD) will be denied as not reasonable and necessary.

Dual Function Ventilator with Cough Stimulation (e.g., React V+C device)  

Must qualify for both:

1. Ventilator (invasive or non-invasive) and
2. Cough assist (mechanical in-exsufflation) device:
   1. Beneficiary must have a neuromuscular disease, and
   2. The condition causes a significant impairment of the chest wall and/or diaphragmatic movement, such that it results in an inability to clear retained secretions
      Coverage is diagnosis driven. Please see the Mechanical In-Exsufflation Policy Article in the References section below for ICD-10 diagnosis codes.

Second Ventilator

Medicare will cover a second ventilator if it is required to serve a different purpose that is determined by the beneficiary’s medical needs. 
Two examples of this are:

• A beneficiary requires one type of ventilator (e.g., a negative pressure ventilator with a chest shell) for part of the day and needs a different type of ventilator (e.g., positive pressure ventilator with a nasal mask) during the rest of the day.
• A beneficiary who is confined to a wheelchair requires a ventilator mounted on the wheelchair for use during the day and needs another ventilator of the same type for use while in bed. Without two pieces of equipment, the beneficiary may be prone to certain medical complications, may not be able to achieve certain appropriate medical outcomes, or may not be able to use the medical equipment effectively.
  

References

• National Coverage Determination - Durable Medical Equipment Reference List (see section regarding Ventilators)
• Local Coverage Determination - Respiratory Assist Devices (see section regarding Ventilators)
• Local Coverage Determination - Mechanical In-Exsufflation Devices
• A52510 - Mechanical In-exsufflation Devices - Policy Article
  

The guidelines below include the following topics.  Click on a topic to go directly to that section.

• Coverage Criteria
• Options and Accessories
• Seating and Back Cushions
• References (Local Coverage Determination and Policy Article)

Coverage Criteria

Manual Wheelchairs

Covered if Criteria A, B, C, D, and E are met and Criterion F or G is met.

1. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that:
   1. Prevents the beneficiary from accomplishing an MRADL entirely, or
   2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL, or
   3. Prevents the beneficiary from completing an MRADL within a reasonable time frame.
2. The beneficiary’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
3. The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.
4. Use of a manual wheelchair will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home.
5. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home.
6. The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.
7. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair. Documentation of the beneficiary’s medical history, use of other equipment, mobility limitations, and ability to use the wheelchair safely must be obtained from the practitioner’s office for a manual wheelchair and accessories.

Standard Hemi Wheelchairs (K0002) are covered if medical documentation establishes that the beneficiary is unable to use a standard wheelchair because the beneficiary requires a lower seat height (17" to 18") due to short stature or to enable a beneficiary to place his/her feet on the ground for propulsion.

Lightweight Wheelchairs (K0003) are covered when a beneficiary cannot propel himself or herself in a standard wheelchair in the home and the beneficiary is actually able to self-propel in a lightweight chair.

High Strength Lightweight Wheelchairs (K0004) are covered when the beneficiary needs the wheelchair while engaging in frequent activities in the home that cannot be performed in a standard or lightweight wheelchair or the beneficiary requires a seat width, depth or height that cannot be accommodated in a standard, lightweight or hemi-wheelchair and spends at least two hours per day in the wheelchair. This type of wheelchair would rarely be medically necessary if the expected duration of need is less than three months.

Ultra-Lightweight Manual Wheelchair (K0005) is covered when the beneficiary is a full-time manual wheelchair user and individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles which cannot be accommodated by a K0001–K0004 manual wheelchair and a specialty evaluation was performed by a licensed/certified medical professional such as a PT, OT or practitioner who is trained and experienced in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. And the wheelchair is provided by a Rehabilitative Technology Supplier that employees RESNA-certified Assistive Technology Professional who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the beneficiary.

Heavy Duty Wheelchairs (K0006) are covered for beneficiaries weighing more than 250 pounds or having severe spasticity.

Extra Heavy Duty Wheelchairs (K0007) are covered for beneficiaries weighing more than 300 pounds.

Transport Chair (E1037, E1038 or E1039) is covered as an alternative to a standard manual wheelchair if the basic coverage criteria are met. 

Wheelchair Options and Accessories

Covered if all of the criteria for the wheelchair has been met and the option/accessory itself is medically necessary.  Refer to the Wheelchair Options/Accessories Local Coverage Determination and Policy Article in the References section below for information regarding specific options/accessory coverage requirements.

Wheelchair Seating and Back Cushions

Covered for beneficiaries who have a Medicare-qualified wheelchair. Coverage for this equipment is diagnosis driven. Refer to the Wheelchair Seating Local Coverage Determination and Policy Article in the References section below for associated ICD-10 diagnosis codes.

References

• Manual Wheelchair Bases
  • Local Coverage Determination - Manual Wheelchair Bases
  • A52497 - Manual Wheelchair Bases - Policy Article 
• Wheelchair Options/Accessories
  • Local Coverage Determination - Wheelchair Options/Accessories
  • A52504 - Wheelchair Options/Accessories - Policy Article 
• Wheelchair Seating and Back Cushions
  • Local Coverage Determination - Wheelchair Seating
  • A52505 - Wheelchair Seating - Policy Article

Automatic External Defibrillator  

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Automatic External Defibrillator
• A52458 - Automatic External Defibrillators - Policy Article 

Bed Pan

Covered for beneficiaries who are bed confined.

Blood Pressure Monitor (Sphygmomanometer)

Covered for beneficiaries with end-stage renal disease (ESRD) as part of a home hemodialysis system when they have chosen to receive supplies and equipment from an independent supplier. 

Breast Prothesis

For information regarding coverage and documentation requirements:

• Local Coverage Determination - External Breast Prostheses
• A52478 - External Breast Prostheses - Policy Article 

Canes and Crutches

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Canes and Crutches
• A52459 - Canes and Crutches - Policy Article

Commode

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Commodes
• A52461 - Commodes - Policy Article

Compression Stockings

Covered when it is used as a primary or secondary dressing over wounds that meet the statutory requirements for a qualifying wound (surgically created or modified, or debrided).

Continuous Blood Glucose Monitor (CGM)

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Glucose Monitors
• A52464 - Glucose Monitor - Policy Article

Continuous Passive Motion Device (CPM)

Covered for patients who have received a total knee replacement. To qualify for coverage, use of the device must commence within 2 days following surgery. In addition, coverage is limited to that portion of the 3-week period following surgery during which the device is used in the patient’s home. There is insufficient evidence to justify coverage of these devices for longer periods of time or for other applications.

Cough Assist - Mechanical In-Exsufflation Device

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Mechanical In-Exsufflation Devices
• A52510 - Mechanical In-exsufflation Devices - Policy Article 

Enteral Equipment, Supplies, and Nutrients

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Enteral Equipment and Supplies
• A58833 - Enteral Nutrition - Policy Article

Humidifier

Covered if it is necessary to the operation of the beneficiary’s covered positive airway pressure (PAP) equipment or Respiratory Assist Device (RAD).

Insulin, Insulin Pump and Supplies

For information regarding coverage and documentation requirements:

• Local Coverage Determination – External Infusion Pumps
• A52507 - External Infusion Pumps - Policy Article

Intermittent Positive Pressure Breathing (IPPB) Machines

Covered if patient’s ability to breathe is severely impaired.

Neuromuscular Electrical Stimulation (NMES)

For information regarding coverage and documentation requirements:

• National Coverage Determination - Neuromuscular Electrical Stimulation Device

Osteogenesis Stimulators (Spinal and Non-Spinal)

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Osteogenesis Stimulators
• A52513 - Osteogenesis Stimulators - Policy Article

Ostomy Supplies

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Ostomy Supplies
• A52487 - Ostomy Supplies - Policy Article

Patient Lift

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Patient Lifts
• A52516 - Patient Lifts - Policy Article

Percussor

Covered for mobilizing respiratory tract secretions in patients with chronic obstructive lung disease, chronic bronchitis, or emphysema, when patient or operator of powered percussor receives appropriate training by a physician or therapist, and no one competent to administer manual therapy is available.

Pneumatic Compression Devices

For information regarding coverage and documentation requirements:

• NCD - Pneumatic Compression Devices (280.6)

Pressure Reducing Support Surfaces

For information regarding coverage and documentation requirements:

Group 1:

• Local Coverage Determination - Group 1 Pressure Reducing Support Surfaces
• A52489 - Pressure Reducing Support Surfaces - Group 1 - Policy Article 

Group 2:

• Local Coverage Determination - Pressure Reducing Support Surfaces - Group 2
• A52490 - Pressure Reducing Support Surfaces - Group 2 - Policy Article

Group 3:

• Local Coverage Determination - Group 3 Pressure Reducing Support Surfaces
• A52468 - Pressure Reducing Support Surfaces - Group 3- Policy Article

Repairs and Replacements

For information regarding coverage and documentation requirements:

• Standard Documentation Requirements for All Claims Submitted to DME MACs  (See the REPAIRS/REPLACEMENT section)

Safety Rollers

Covered if beneficiary meets Mobility Assistive Equipment clinical criteria.

For additional information:

• National Coverage Determination - Mobility Assistive Equipment

Seat Lift Mechanism

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Seat Lift Mechanisms
• A52518 - Seat Lift Mechanisms - Policy Article

Sitz Bath

Covered if the beneficiary has been diagnosed with an infection or injury of the perineal area and the practitioner has prescribed the sitz bath as part of a planned regimen of home care treatment.

Suction Pumps and Supplies (suction catheters, tape, tubing, tape, etc.)

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Suction Pumps
• A52519 - Suction Pumps - Policy Article

Covered when medically necessary for the treatment following a surgical procedure or when debridement of a wound is medically necessary.

Tracheostomy Care Kits

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Tracheostomy Care Supplies
• A52492 - Tracheostomy Care Supplies - Policy Article

Traction Equipment

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Cervical Traction Devices
• A52476 - Cervical Traction Devices - Policy Article

Transcutaneous Electrical Nerve Stimulator (TENS) and Supplies

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Transcutaneous Electrical Nerve Stimulators
• A52520 - Transcutaneous Electrical Nerve Stimulators (TENS) - Policy Article

Ultraviolet Light Cabinet

Covered for selected beneficiaries with generalized intractable psoriasis, if medical and other factors justify treatment at home, rather than at an alternative site, such as the out-patient department of a hospital.

For additional information:

• National Coverage Determination - Treatment of Psoriasis

Urological Supplies (Indwelling Catheters, Drainage Bags, Urinary Catheters, etc.)

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Urological Supplies
• A52521 - Urological Supplies - Policy Article

Walkers

For information regarding coverage and documentation requirements:

• Local Coverage Determination - Walkers
• A52503 - Walkers - Policy Article

Durable Medical Equipment Reference List

Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)