Updates to Clinical Coverage Policy 5A-2, Respiratory Equipment and Supplies

Tuesday, October 20, 2020

All temporary Durable Medical Equipment (DME) policy flexibilities outlined in COVID-19 Special Bulletins remain in effect as of this publication date. See COVID-19 Special Bulletins for details.

An amended version of Clinical Coverage Policy 5A-2, Respiratory Equipment and Supplies with an effective date of Oct. 1, 2020, was posted to the NC Medicaid Clinical Coverage Policy web page. Following is a summary of updates:

In Subsection 5.3.1, Oxygen, Oxygen Supplies and Equipment, under the subheading Requirements for Qualifying Oxygen Analysis and Coverage, the first medical necessity criterion was updated to clarify age requirements for a qualifying oxygen analysis during an inpatient hospital stay, such that it now reads:

  • For beneficiaries 21 years of age and older, if the oxygen analysis is performed during an inpatient hospital stay, the reported test must be one obtained closest to, but no earlier than, two (2) calendar days prior to the hospital discharge date. For beneficiaries under 21 years of age, the reported test may be one obtained at any time during the inpatient hospital stay.

In Subsection 5.3.2, the following updates were made:

  • The medical necessity criteria for respiratory assist devices to manage central sleep apnea and obstructive sleep apnea were updated to indicate that qualifying polysomnograms must be provided according to the requirements listed in Clinical Coverage Policy 1A-20, Sleep Studies and Polysomnography Services.
  • Under the subheading Nebulizers, the prior authorization requirement for ultrasonic nebulizers was removed. 
  • Under the subheading Oximeters, language was clarified to indicate that existing medical necessity criteria are for hospital grade, table-top oximeters for rental and a qualifying criterion for infants was added. Additionally, coverage was added for portable oximeters for purchase and the following medical necessity criteria, without PA, were added:
    • A portable oximeter may be considered medically necessary for beneficiaries who are required by their medical provider to independently monitor and report their blood oxygen levels noninvasively from home for any one of the following indications:
      a)    To evaluate initial and ongoing medical necessity of an oxygen therapeutic regimen; 
      b)    To evaluate appropriate home oxygen liter flow for ambulation, exercise, or sleep in an individual with respiratory disease;
      c)    To evaluate an acute change in condition requiring an adjustment to the liter flow of home oxygen.
    • Prior approval for a portable oximeter is not required.
    • Note: An oximeter for home use may not be considered an appropriate method of monitoring patients with asthma or when used alone as a screening/testing technique for suspected obstructive sleep apnea (OSA).

In Attachment A: Claims-Related Information, Section B, ICD-10-CM Diagnosis Code(s) were updated for Cough Stimulating Devices.

In Attachment A: Claims-Related Information, Section C: Procedure Code(s), the following updates were made:

  • The existing row for HCPCS code E0445 (oximeter device for measuring blood oxygen levels non-invasively) was designated “rental only” and a second row for E0445 as a purchase option with a lifetime expectancy of three years was added.

In the DME fee schedule, the asterisk indicating an item requires PA was removed from HCPCS code E0575 (nebulizer, ultrasonic).

Additional Resources

The DME fee schedule and full text of Clinical Coverage Policy 5A-2, Respiratory Equipment and Supplies is available at North Carolina Medicaid’s

Durable Medical Equipment web page. All COVID-19 Special Bulletins are available here.

Contact

NC Medicaid Contact Center, 888-245-0179