An amended version of Clinical Coverage Policy 5A-2, Respiratory Equipment and Supplies with an effective date of Aug. 1, 2022, was posted to the NC Medicaid Clinical Coverage Policy web page. Following is a summary of updates:
In Subsection 5.3.2 Respiratory Devices for the Treatment of Respiratory Disorders other than Obstructive Sleep Apnea (OSA) the following medical necessity criteria for a secondary ventilator have been added:
A secondary ventilator may be medically necessary if it is required to serve a different purpose than the primary ventilator as determined by the beneficiary’s medical needs. Situations where a second ventilator may be medically necessary may include, but are not limited to:
- A beneficiary requires one type of ventilator such as a negative pressure ventilator with a chest shell for part of the day and needs a different type of ventilator such as a positive pressure ventilator with a nasal mask during the rest of the day.
- A beneficiary who is confined to a wheelchair and requires a ventilator mounted on the wheelchair for use during the day and another ventilator for use while in bed.
Note: Back-up ventilators are not covered by NC Medicaid. A back-up ventilator is defined as an identical or similar device used to meet the same medical needs as the primary ventilator or provided as a precaution in case of malfunction of the primary ventilator.
In Attachment A: Claims-Related Information, Section C: Procedure Code(s), the following updates were made:
Quantity limits were updated for existing HCPCS codes:
HCPCS code |
Description |
Unit limit prior to 8/1/2022 |
Unit limit on and after 8/1/2022 |
|
A7002 |
Tubing, used with suction pump, each |
2 per month |
4 per month |
|
A7003 |
Administration set, with small volume nonfiltered pneumatic nebulizer, disposable |
1 per month |
2 per month |
|
A7013 |
Filter, disposable, used with aerosol compressor or ultrasonic generator |
1 per month |
2 per month |
|
A7027 |
Combination oral/nasal mask, used with continuous positive airway pressure device, each |
2 per year |
4 per year |
|
A7028 |
Oral cushion for combination oral/nasal mask, replacement only, each |
2 per year |
2 per month |
|
A7029 |
Nasal pillows for combination oral/nasal mask, replacement only, pair |
2 per year |
2 per month |
|
A7030 |
Full face mask used with positive airway pressure device, each |
2 per year |
4 per year |
|
A7031 |
Face mask interface, replacement for full face mask, each |
2 per year |
1 per month |
|
A7032 |
Cushion for use on nasal mask interface, replacement only, each |
2 per year |
2 per month |
|
A7033 |
Pillow for use on nasal cannula type interface, replacement only, pair |
2 per year |
2 per month |
|
A7034 |
Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap |
2 per year |
4 per year |
|
A7036 |
Chinstrap used with positive airway pressure device |
1 per year |
2 per year |
|
A7037 |
Tubing used with positive airway pressure device |
2 per year |
4 per year |
|
A7038 |
Filter, disposable, used with positive airway pressure device |
1 per month |
2 per month |
|
Coverage and quantity limits were added for HCPCS codes A4619 (face tent), A7014 (filter, nondisposable, used with aerosol compressor or ultrasonic generator), E0572 (aerosol compressor, adjustable pressure, light duty for intermittent use), E0574 (ultrasonic/electronic aerosol generator with small volume nebulizer), E0585 (nebulizer, with compressor and heater), and E1372 (immersion External Heater for Nebulizer).
Additional Resources
The Durable Medical Equipment (DME) fee schedule and full text of Clinical Coverage Policy 5A-2, Respiratory Equipment and Supplies is available at NC Medicaid’s Durable Medical Equipment (DME) web page.
Contact
NC Medicaid Contact Center, 888-245-0179