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Indications for Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders are discussed in a separate policy.
Indications for Oxygen Therapy are discussed in a separate policy.
Indications for Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure are discussed in a separate policy.
Indications for the Measurement of Exhaled Nitric Oxide in the Diagnosis and Management of Asthma and Other Respiratory Disorders are discussed in a separate policy.
Indications for Home Apnea Monitors are discussed in a separate policy.
Indications for the treatment of Sleep Disorders are discussed in a separate policy.
Pulse Oximetry for Home Use is discussed in a separate policy.
POLICYThe following respiratory devices are considered medically necessary:
For coverage criteria of pulse oximetry in the home setting, refer to the Pulse Oximetry for Home Use medical policy.
When noninvasive ear or pulse oximetry testing is performed in a professional's office, it is considered integral to the professional's medical or surgical care. Therefore, the device is not a distinct or separate service, and separate payment will not be made for the pulse oximeter in these instances.
Computerized peak flow meters (including AirWatch®). Special features such as computerized recording devices are considered convenience enhancements and are not eligible for additional coverage.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Nervous/Mental Conditions, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Member, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.
For the definition of Medically Necessary, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
POLICY HISTORY2/1988: DME Manual specifies pulse oximeter coverage
8/1997: Approved by Medical Policy Advisory Committee (MPAC) as Vest Percussor
8/1998: MPAC approved limitation to ThAIRapy® Bronchial Vest/System; policy renamed Oscillatory Devices for Treatment of Cystic Fibrosis
11/1999: Additional respiratory devices approved by MPAC; policy renamed
5/9/2001: Device name change added; ABI VEST® Airway Clearance System (formerly know as ThAIRapy® Vest)
2/7/2002: "The following respiratory devices are not covered" changed to "not medically necessary"
5/2/2002: Type of Service and Place of Service deleted
3/7/2003: Code Reference section updated
7/18/2003: Device name change added: Vest™ Airway Clearance System (formerly known as ABI Vest® Airway Clearance System and ThAIRapy® Vest)
7/2/2004: Oscillary devices added to Policy Guidelines
10/18/2005: Code Reference section updated; HCPCS: E0481 added
9/22/2006: Coding updated. CPT4/HCPCS 2006 revisions added to policy
10/02/2006: Policy updated, all devices not medically necessary
10/5/2006: Coding updated. HCPC codes A7025, A7026, E0481, E0483, E1399 moved to non-covered table. S8185 added to policy
9/24/2009: Description Section revised to include links to Oscillatory Devices for the Treatment of Cystic Fibrosis and Other Respiratory Disorders Medical Policy, Oxygen Medical Policy, Inhaled Nitric Oxide as a Treatment of Hypoxic Respiratory Failure Medical Policy, Measurement of Exhaled Nitric Oxide in the Diagnosis and Management of Asthma and Other Respiratory Disorders Medical Policy, Home Apnea Monitors Medical Policy, Sleep Disorders Medical Policy, and Aerosolized Antibiotics as a Treatment of Chronic Sinusitis Medical Policy. Information on Cystic fibrosis and oscillatory devices removed. Policy Statement Section revised to remove oscillatory devices information. Coding Section revised to remove ICD9 Diagnosis code 277.0 from Covered Codes Table, and revised to remove HCPCS codes A7025, A7026, E0481, E0483, E0484, S8185 from Non-Covered Codes Table. Verbiage added to Covered Codes Table, "* Some covered procedure codes may have multiple descriptions. Coverage will only be made for covered codes when used for services outlined within the policy statement section". Verbiage added to Non-Covered Codes Table, "*This is not an all inclusive list of non-covered procedure codes."
10/19/2009: Coding Section updated to add HCPCS codes S8096, S8097, S8100, and S8101 to the Covered Codes Table, CPT codes 94760, 94761, and 94762 added to the Non-Covered Codes Table, Added verbiage to HCPCS code E1399 (may use for coding the AirWatch® system) under the Non-Covered Codes Table.
06/21/2011: Added link to the Pulse Oximetry for Home Use medical policy and deleted the following policy statement: "In a home setting, a health care professional is not available to evaluate and respond to the data obtained from a pulse oximeter. Therefore, the device is considered inappropriate for home use and is not a covered service."
08/31/2015: Medical policy revised to add ICD-10 codes. Removed ICD-9 procedure code 93.18 from the Covered Codes table in the Code Reference section.
05/31/2016: Policy number L.1.01.406 added. Policy Guidelines updated to add medically necessary definition.
SOURCESBlue Cross & Blue Shield Association policy #1.01.15
Hayes Medical Technology Directory
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.