Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-552 - Respiratory care
CPAP/BI-LEVEL RAD
Section 182-552-0500 - Respiratory care - Covered - Bi-level respiratory assist devices and supplies
Universal Citation: WA Admin Code 182-552-0500
Current through Register Vol. 24-18, September 15, 2024
(1) The medicaid agency covers, without prior authorization, one bi-level respiratory assist device (RAD), with or without a back-up rate feature, per client every five years. The client must have a clinical disorder characterized as one of the following and meet the clinical criteria for the specific condition as listed in subsections (2) through (5) of this section.
(a) Restrictive thoracic disorders (e.g.,
neuromuscular diseases or severe thoracic cage abnormalities); or
(b) Severe chronic obstructive pulmonary
disease (COPD); or
(c) Central
sleep apnea or complex sleep apnea; or
(d) Hypoventilation syndrome.
(2) Restrictive thoracic disorders - The medicaid agency pays for, without prior authorization, a bi-level RAD either with or without the back-up rate feature, when all of the following clinical criteria are met:
(a) The client has
been diagnosed with a neuromuscular disease (e.g., amyotrophic lateral
sclerosis (ALS)) or a severe thoracic cage abnormality (e.g.,
post-thoracoplasty for tuberculosis); and
(b) Chronic obstructive pulmonary disease
(COPD) does not contribute significantly to the individual's pulmonary
limitation; and
(c) One or more of
the following criteria are met:
(i) An
arterial blood gas PaCO2, done while awake and breathing
the client's prescribed FIO2 (fractionated inspired
oxygen concentration) is greater than or equal to forty-five mm Hg;
or
(ii) Sleep oximetry demonstrates
oxygen saturation less than or equal to eighty-eight percent for greater than
or equal to five minutes of nocturnal recording time (minimum record time of
two hours), done while breathing the client's prescribed recommended
FIO2; or
(iii) For a neuromuscular disease (only),
either of the following:
(A) Maximal
inspiratory pressure is less than sixty cm H2O;
or
(B) Forced vital capacity is
less than or equal to fifty percent predicted.
(3) Severe chronic obstructive pulmonary disease (COPD).
(a) The medicaid
agency pays, without prior authorization, for a bi-level RAD, without the
back-up rate feature, when all of the following clinical criteria are met:
(i) An arterial blood gas
PaCO2, done while awake and breathing the client's
prescribed FIO2, is greater than or equal to fifty-two
mm Hg; and
(ii) Sleep oximetry
demonstrates oxygen saturation less than or equal to eighty-eight percent for
greater than or equal to five minutes of nocturnal recording time (minimum
recording time of two hours), done while breathing oxygen at two LPM or the
client's prescribed FIO2, whichever is higher;
and
(iii) Prior to initiating
therapy, obstructive sleep apnea and treatment with CPAP has been considered
and ruled out.
(b) The
medicaid agency pays, without prior authorization, for a bi-level RAD, with the
back-up rate feature, for clients with COPD who qualified for a bi-level RAD
under (3)(a) of this section when:
(i)
Started any time after a period of initial use of the bi-level RAD without the
back-up rate feature when both of the following clinical criteria are met:
(A) An arterial blood gas
PaCO2, done while awake and breathing the client's
prescribed FIO2, shows that the client's
PaCO2 worsens greater than or equal to seven mm Hg
compared to the original result from criterion in subsection (3)(a)(i) of this
section; and
(B) A facility-based
PSG demonstrates oxygen saturation less than or equal to eighty-eight percent
for greater than or equal to five minutes of nocturnal recording time (minimum
recording time of two hours) while using a bi-level RAD without the back-up
rate feature that is not caused by obstructive upper airway events, i.e., AHI
less than five; or
(ii)
Started at a time no sooner than sixty-one days after initial issue of the
bi-level RAD without the back-up rate feature, when both of the following
clinical criteria are met:
(A) An arterial
blood gas PaCO2 is done while awake and breathing the
client's prescribed FIO2, still remains greater than or
equal to fifty-two mm Hg; and
(B)
Sleep oximetry while breathing with the bi-level RAD without back-up rate
feature, demonstrates oxygen saturation less than or equal to eighty-eight
percent for greater than or equal to five minutes of nocturnal recording time
(minimum recording time of two hours), done while breathing oxygen at two LPM
or the client's prescribed FIO2, whichever is
higher.
(4) Central sleep apnea or complex sleep apnea (i.e., not due to airway obstruction). The medicaid agency pays for, without prior authorization, a bi-level RAD with or without the back-up rate feature, when the client's polysomnogram test reveal all of the following:
(a) The diagnosis of central sleep apnea
(CSA) or complex sleep apnea (CompSA);
(b) Significant improvement of the
sleep-associated hypoventilation with the use of a bi-level RAD with or without
the back-up rate feature on the settings that will be prescribed for initial
use at home, while breathing the client's prescribed
FIO2.
(5) Hypoventilation syndrome.
(a) The medicaid agency pays for, without
prior authorization, a bi-level RAD without the back-up rate feature, when the
clinical criteria in (a)(i) and (ii) of this subsection, or either (a)(iii) or
(iv) of this subsection are met:
(i) An
initial arterial blood gas PaCO2, done while awake and
breathing the client's prescribed FIO2, is greater than
or equal to forty-five mm Hg; and
(ii) Spirometry shows an FEV1/FVC greater or
equal to seventy percent and an FEV1 greater than or equal to fifty percent of
predicted; or
(iii) An arterial
blood gas PaCO2, done during sleep or immediately upon
awakening, and breathing the client's prescribed FIO2,
shows the client's PaCO2 worsened greater than or equal
to seven mm Hg compared to the original result in (a) of this subsection;
or
(iv) A facility-based PSG
demonstrates oxygen saturation less than or equal to eighty-eight percent for
greater than or equal to five continuous minutes of nocturnal recording time
(minimum recording time of two hours) that is not caused by obstructive upper
airway events, i.e., AHI less than five.
(b) The medicaid agency pays for, without
prior authorization, a bi-level RAD with the back-up rate feature, when the
clinical criteria in (b)(i) and (ii) of this subsection, and either (b)(iii) or
(iv) of this subsection are met:
(i) A
covered bi-level RAD without the back-up rate feature is being used;
and
(ii) Spirometry shows an
FEV1/FVC greater than or equal to seventy percent and an FEV1 greater than or
equal to fifty percent of predicted; and
(iii) An arterial blood gas
PaCO2, done while awake and breathing the client's
prescribed FIO2, shows that the client's
PaCO2 worsens greater than or equal to seven mm Hg
compared to the ABG result performed to qualify the client for the bi-level RAD
without the back-up rate feature; or
(iv) A facility-based PSG demonstrates oxygen
saturation less than or equal to eighty-eight percent for greater than or equal
to five continuous minutes of nocturnal recording time (minimum recording time
of two hours) that is not caused by obstructive upper airway events, i.e., AHI
less than five while using a bi-level RAD without the back-up rate
feature.
(6) For a bi-level RAD without the back-up rate feature, the medicaid agency pays as follows:
(a) An initial three-month rental
period. In accordance with medicare's guidelines, the medicaid agency requires
a face-to-face clinical reevaluation of the client by the treating authorized
prescriber, between day thirty-one and day ninety-one of the rental period,
which documents the following in the client's file to continue rental:
(i) The progress of the client's relevant
symptoms; and
(ii) The client's
compliance with using the device.
(b) Purchases after the requirements of (a)
of this subsection are met.
(7) For a bi-level RAD with the back-up rate feature used with:
(a) An invasive interface,
the medicaid agency pays for the rental only.
(b) A noninvasive interface, the medicaid
agency pays as follows:
(i) An initial
three-month rental period. In accordance with medicare's guidelines, the
medicaid agency requires a face-to-face clinical reevaluation of the client by
the treating authorized prescriber, between day thirty-one and day ninety-one
of the rental period, which documents the following in the client's file to
continue rental:
(ii) The progress
of the client's relevant symptoms; and
(iii) The client's compliance with using the
device.
(iv) Purchase after a total
of thirteen months of rental.
(8) Prior authorization is required if the client does not meet the clinical criteria in this section or if the medicaid agency has purchased a CPAP device or other respiratory assist device for the client within the last five years.
(9) Replacement of bi-level RAD. The medicaid agency's policy for replacement of a bi-level RAD is the same as for a CPAP device. See WAC 182-552-0400(6).
Statutory Authority: RCW 41.05.021. 12-14-022, §182-552-0500, filed 6/25/12, effective 8/1/12.
Disclaimer: These regulations may not be the most recent version. Washington may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
