Medicare Coverage Form

Medicare's Coverage Criteria for CPAP

The beneficiary has a sleep test (as defined below) that meets either of the following criteria (1 or 2):

1. The apnea-hypopnea 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:
   1. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; OR
   2. Hypertension, ischemic heart disease, or history of stroke.

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Medicare's Coverage Criteria for LAL

Patient has large or multiple Stage III or IV pressure ulcers on the trunk or pelvis (Large = 8 sq centimeters, please explain in detail)

OR

Patient has multiple (2 or +) Stage II pressure ulcers on the trunk or pelvis which have failed to improve over the past month. The beneficiary has been on a comprehensive ulcer treatment program that would include EACH of the following:

• Use of appropriate group I Support Surface (specify which)
• Regular assessment by RN, physician or other licensed practitioner (provide documentation from all assessments, being as specific as possible)
• Appropriate turning and positioning (should be included in assessments)
• Appropriate wound care (explain what was done, be specific)
• Appropriate management of moisture/incontinence (Document incontinence and what is being done to prevent skin breakdown; be specific)
• Nutritional assessment and intervention consistent with overall plan of care (please be specific)

OR

Has had a recent myocutaneous flap or skin graft on the trunk or pelvis

AND

Patient has recently been on a Group II or III Support Surface immediately prior to a recent discharge from a hospital or nursing facility

 

**Pressure Wound sizing, staging and location must be documented in medical record Mattress only applies in conjunction with a hospital bed due to safety and need to strap down device to bed frame.

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Medicare's Coverage Criteria for Wheelchair

• Patient medical condition limits mobility or significantly impairs mobility-related activities of daily living (MRADL: Toileting, Bathing, Feeding, Dressing, Grooming, etc.) *Identify underlying conditions causing mobility limitation, what specific MRADL is impaired and how
  • HOW:
    • Prevents patient from accomplishing MRADL entirely, OR
    • Places patient at reasonably determined heightened risk of morbidity/mortality secondary to attempts to perform an MRADL, OR
    • Prevents pt from completing MRADL within reasonable time frame
• Patient’s mobility limitation cannot be resolved with use of Cane or Walker (Explain why)
• Patient’s living space provides adequate access between rooms, maneuvering space and surface for use of WC (Use in your own words)
• Use of WC will significantly improve ability to perform MRADLs and patient will use it on a regular basis in living space (Provide specific activities that will be possible, must mention use in home)
• Patient has not expressed unwillingness to use manual WC in home (Patient must be willing to use)

AND

Patient has sufficient upper extremity function/other physical or mental capabilities needed to safely self propel in home, daily (Limitations of strength, endurance, range of motion, coordination, presence of pain, deformity or absence of one/or both upper extremities are relevant to assessment of upper extremity function)

OR

Patient has caregiver who is available, willing and able to provide assistance with WC (who is caregiver, how often available)

 

Lightweight wheelchair: Cannot self propel in standard wc and can/does self propel in lw chair (Does not apply if reliance on caregiver)

Hemi height wheelchair: requires a lower seat height of 17” or 18” because: short stature or need to place feet on ground

Heavy duty wheelchair: patient weighs over 250lbs (documented weight listed in chart notes)

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Medicare's Coverage Criteria - Testing and Results

Oxygen qualification testing must be performed at the time of need which 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 oxygen initially prescribed at the time of hospital discharge, testing must be performed within 2 days prior to discharge. This rule does not apply to discharges from SNF.

The following 3 options are acceptable oximetry testing methods:

1. At rest and awake – often referred to as "spot" oximetry - and client has O2 saturation of 88% or below
2. During exercise – requires a series of 3 tests done during a single testing session:
   
   1. At rest, off oxygen – showing a non-qualifying result (O2 sat above 88%)
   2. Exercising, off oxygen – showing a qualifying result (O2 sat below 88%)
   3. Exercising, ON oxygen – tests results obtained while exercising with oxygen therapy showed improvement
      O2 sat (usually 90% or above)
      
      1. *If a patient needs > 4 LPM, you must prove the patient is still ≤88% while using 4 LPM, and then improves
         with LPM greater than 4.
3. During sleep
   
   1. Overnight sleep oximetry (may be done in the hospital or home)
      
      1. Just needs to de-sat to 88% or below once, no time requirement
      2. Cannot be used to prescribe oxygen for PAP user
   2. Titration polysomnogram (in-lab)
      
      1. Must be used for clients with sleep apnea to establish that the sleep apnea is appropriately and sufficiently treated before oxygen saturation results obtained during sleep testing are considered qualifying.

 

**There are additional situations for clients who have oxygen saturation levels of exactly 89% and for clients needing oxygen for cluster headaches. Please consult a member of Bellevue Healthcare's Respiratory Team to discuss those situations if applicable.

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Medicare's Coverage Criteria For Hospital Bed

Patient requires changes in body position and/or has an immediate need for change in body position (Explain why, provide a specific example)
AND
Patient requries head of bed elevation >30 degrees most of the time due to CHF, COPD, or problems with aspiration (Provide specific example of how affects patient, why bed would help)

 

**Medicare does NOT cover Full Electric Bed OR HI-LO Electric Bed

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