Home Care New England - Medicare and Insurance Guidelines

Medicare Oxygen Coverage Guidelines
Medicare CPAP Coverage Guidelines
List of accepted major insurances

Medicare Oxygen Coverage Guidelines

Laboratory Result	Action
Group I: PaO2 at or below 55mm Hg or SaO2 at or below 88% (awake and at rest)	Acceptable for Medicare Coverage. Note: May be covered for nocturnal use only if: * Levels are higher than noted, but drop to Group I levels during sleep, OR * Levels are higher than noted, but during sleep drop > 10mm HG (ABGs) or > 5% (O2 Sat) from awake/at rest levels, AND are associated with demonstrated cor pulmonale, pulmonary hypertension and erythrocytosis. Note: May be covered for exercise only if: * Levels are higher than noted, but drop to Group I levels during exercise and it can be documented that supplemental oxygen improves the hypoxemia demonstrated during exercise on room air.
Group II: PaO2 = 56-59mm Hg or SaO2 = 89% (awake and at rest)	Requires Documentation of: * Dependent edema suggesting congestive heart failure, OR * Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, or "P" pulmonale of EKG (P wave >3mm in standard leads II, III or AVF) OR * Erthrocythermia with Hct > 56%

Use CMN DMERC Form 484.2. Recertification required 12 months after initial CMN if the patient starts out with Group I blood gas levels (submit most recent available ABG or O2 Sat.) Recertification required within 90 days if the initial levels fall into Group II (submit repeat ABG or O2 sat) performed between 61st and 90th day. Recertfication also due at the expiration of a period of estimated medical need. Revised CMN required with change in prescription or change in ordering physician.

Group III:
PaO2 at or above 60mm Hg
or
SaO2 at or above 90%

* Presumes not medically necessary
* Extensive physician documentation required for approval.

Demonstration of hypoxemia is accomplished by either arterial blood gases (ABGs) or measurement of oxygen saturation (O2 Sat.) If both tests are available, ABGs should be submitted with CMN. It is no longer necessary that tests be performed with the patient on room air only. Tests should be done while patient is already in a chronic stable state as an outpatient or within two calendar days before hospital discharge.

Portable Oxygen Requirements
Medicare coverage of a portable oxygen system, alone or to complement a stationary oxygen system, may be allowed if the patient is mobile within the home.

Oxygen CMN - Physician Information (Section B, DMERC Form 484.2)

Questions #1 & #7

This should be the most recent test or prior to the most recent date at the top of Section A. If both ABG and SaO2 tests are performed on that same day, only report PaO2. If the patient's levels are low enough to qualify for Medicare coverage while breathing supplemental oxygen, then test in Question #1 may be performed with patient on oxygen. However, titrate the flow down to a level where Medicare criteria are clearly met. (If criteria are not met, provide additional information justifying medical necessity.)

Questions #2

If the answer is "no", provide additional information justifying medical necessity.

Questions #4

Medicare does not accept a test performed by the oxygen supplier (except when the supplier is a hospital-owned company and the test is performed by the hospital.)

Questions #6

If different flow rates are prescribed for different situations (e.g. at rest, during exercise, during sleep), enter the highest value in this question. Other values can be noted in Section C.

Questions #7

Leave blank if the prescribed flow rate in question #6 is less than or equal 4LPM.

Questions #8-10

Circle "Y" or "N" if reported results in Question #1 show a PaO2 greater than 55mm Hg or an SaO2 greater than 88%. Otherwise, circle "D" for "does not apply."

Medicare CPAP Coverage Guidelines A single level continuous positive airway pressure (CPAP) device (E0601) is covered for the treatment of obstructive sleep apnea (OSA) if criteria A - C are met: A. The patient has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the patient for obstructive sleep apnea. Physicians shall document the face-to-face clinical evaluations and re-evaluations in a detailed narrative note in their charts in the format that they use for other entries. For the initial evaluation, the report would commonly document pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation: 1. History a. Signs and symptoms of sleep disordered breathing including snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches: b. Duration of symptoms c. Validated sleep hygiene inventory such as the Epworth Sleepiness Scale 2. Physical Exam a. Focused cardiopulmonary and upper airway system evaluation b. Neck circumference c. Body Mass Index (BMI) B. The patient has a Medicare-covered sleep test that meets either of the following criteria (1 or 2): 1. The apnea-hyponea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or, 2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of: a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, b. Hypertension, ischemic heart disease, or history of stroke C. The patient and/or caregiver has received instruction from the supplier of the CPAP device and accessories in the proper use and care of the equipment. For continued coverage beyond the first three months of therapy: Continued coverage of PAP devices (E0470 or E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the treating physician must conduct a clinical re-evaluation and document that the beneficiary is benefiting from PAP therapy. For PAP devices with initial dates of service on or after November 1, 2008, documentation of clinical benefits is demonstrated by: 1. Face-to-face clinical re-evaluation by the treating physician with documentation that symptoms of obstructive sleep apnea are improved; and, 2. Objective evidence of adherence to use of the PAP device reviewed by the treating physician. Adherence to therapy is defined as use of PAP>/= 4 hours per night on 70% of the nights during a nonselective thirty (30) day period anytime during the first three (3) months of initial usage.
Insurances Accepted by HomeCare New England
HomeCare New England is a preferred provider for most major insurances. Please contact us for a complete list. Insurances include:
Medicare Medicaid Aetna BC/BS BMC HealthNet Plan Commonwealth Care Harvard Pilgrim Healthcare/First Seniority TricaFreedom	Neighborhood Health Plan Senior Whole Health Tufts Health Plan/Tufts Medicare Preferredre United Health Care AARP – Healthcare Banker’s Life and Casualty Federal Employee Program	Healthmate Homelink Integrated Healthcare Lifespan Blue Northwoods Oxford Life Insurance Company Plan 65 RI Medical Assistance

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