Courtesy of

Ph: 877-236-8494 • Fx: 800-783-5756 www.comfortsleepservices.net cut away

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To our valued physicians: The world of PAP and Oxygen therapy is a complex one. Thankfully, there are many choices designed to help a wide range of patients. We hope you find this guide valuable, and we encourage you to contact us with any questions. We’re here to help. Sincerely, The staff at Comfort Sleep Services

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Medicare Coverage Criteria initial coverage

CPAP (E0601) • Face-to-face clinical evaluation by treating physician prior to a sleep test to assess patient for obstructive sleep apnea. • Medicare-covered sleep test that meets either one of the following criteria: ○ AHI or RDI ≥ 15 events per hour with a minimum of 30 events or ○ AHI or RDI ≥ 5 to 14 events per hour with a minimum of 10 events and documentation of excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; OR hypertension, ischemic heart disease or history of stroke. cut away

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Cover for RAD without backup (E0470) • RAD without backup is covered for patients with OSA if patient meets initial coverage criteria for CPAP and the CPAP was tried and proved ineffective based on therapeutic trial conducted in either a facility or home setting. • RAD with backup (E0471) not medically necessary for the primary treatment of OSA. Requirements to continue coverage past 90 days Continued coverage requires that, no sooner than the 31st day but no later than the 91st day after initiating therapy, the treating physician must conduct a clinical re-evaluation and document that the beneficiary is benefiting from PAP therapy.

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Documentation The ordering physician is responsible for the following documentation: CPAP (E0601) •

A face-to-face clinical re-evaluation by the treating physician with documentation that symptoms of obstructive sleep apnea are improved; and

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Objective evidence of adherence to use of the PAP device, reviewed by the treating physician (adherence to therapy is defined as the use of PAP ≥ per night on 70 percent of nights during a consecutive 30-day period anytime during the first three months of initial use).

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Note: Documentation of adherence to PAP therapy shall be accomplished through direct download of usage data with documentation provided in a written report format to be reviewed by the treating physician and included in the beneficiary’s medical report. Copies of chart notes should be provided to the PAP device provider.

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Detailed order for CPAP with example Detailed written orders should include:

Acceptable detailed written order

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Basic elements

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○ Beneficiary’s name



○ Detailed description of item



○ All options or additional features



○ Physician’s signature



○ Date order is signed



○ Initial date if dispensed on verbal order



○ Length of need for rental items and supplies

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May be completed by someone other than physician, BUT treating physician must review, sign and date.

• Acceptable orders

○ Fax



○ Photocopy



○ Electronic



○ Original pen and ink

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Must state confirmation of verbal order and from whom the order was received.

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www.respironics.com

cut away RESPIRONICS

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System One REMstar Pro Provides up to 30 days of breath-by-breath auto CPAP therapy. Based on the results of the auto trial, it will automatically convert to the 90 percent pressure to CPAP-Check mode. CPAP-Check mode tracks the patient’s condition for life and can change every 30 hours, plus or minus 1 cm H2O, to meet the patient’s changing needs. Sample Script q Auto-Trial mode q CPAP-Check mode Duration________days (3-30) ________cm H2O (4-20) Min. ________cm H2O (4-20 cm) C-Flex+ (Set to patient comfort) Max.________cm H2O (4-20 cm) A-Flex setting ________(1, 2, 3) Post-Trial CPAP-Check mode @ 90% pressure (± 3 cm)

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REMstar Auto A-Flex Philips Respironics’ clinically proven auto CPAP algorithm now has two additional therapy modes: Auto-Trial and CPAP-Check modes. This innovative technology aids the caregiver in performing shortterm auto CPAP trials and automatically converts to CPAP-Check mode to meet the patient’s changing needs.

Sample Script Min. ________cm H2O (4-20 cm) Max.________cm H2O (4-20 cm) A-Flex setting ________(1, 2, 3) OptiStart (Set to patient comfort)

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q Auto-Trial mode q CPAP-Check mode Duration________days (3-30) ________cm H2O (4-20) Min. ________cm H2O (4-20 cm) C-Flex + (Set to patient comfort) Max.________cm H2O (4-20 cm) A-Flex (Set to patient comfort) Post-Trial CPAP-Check mode @ 90% pressure (± 3 cm)

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Bi-PAP Auto Delivers a level of comfort that can mean the difference between compliance and non-compliance for patients who have difficulty adapting to traditional CPAP therapy. Remote switching between bi-level and CPAP modes, increased humidity output and control and reduced noise levels. Appropriate for patients with Apnea Hypopnea Index, Flow Limitation, Respiratory Effort Related Arousal, snore, leak, Clear Airway Apnea, Obstructed Airway Apnea, Hypopnea and Period Breathing. Sample Script Max IPAP _______cm H2O Min EPAP*_______cm H2O (4-25 cm) *EPAP must be lower than IPAP Max delta _______cm H2O (3-8 cm) Bi-flex setting _______(1, 2, 3) PS min __________ (0-8 cm) PS max __________ (PSmin-8 cm)

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Bi-PAP ST A non-invasive device used for the most complex sleep breathing disorders, such as neuromuscular conditions, COPD and obesity hypoventilation. IPAP and EPAP pressures: Up to 25 cm H2O CPAP pressures: Up to 20 cm H2O Sample Script Mode: q S/T q S EPAP pressure _______ cm H2O (4-25 cm) IPAP pressure _______ cm H2O (4-25 cm) Mode: q CPAP CPAP pressure _______cm H2O (4-20 cm)

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Rate_______ BPM (off, 1-30) S/T only

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Bi-PAP AVAPS Mechanically assists breathing in order to treat disease symptoms, such as those caused by neuromuscular disease and chronic obstructive pulmonary disease. Automatically adapts to disease progression and changing patient needs. Improves ventilation efficacy and simplifies the titration process. IPAP and EPAP pressures: 4 to 25 cm H2O CPAP: 4 to 20 cm H2O Sample Script Mode: q CPAP q S q S/T q T q PC EPAP _______ cm H2O (4-25 cm) (S/T, T, PC modes) IPAP _______ cm H2O (4-25 cm) (S/T, T, PC modes) Rate_______ BPM (off, 1-30) q AVAPS feature: IPAP min _______cm H2O (4-30 cm) (EPAP-IPAP max) IPAP max _______cm H2O (4-30 cm) VT: _______mL (200-1500 mL)

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Bi-PAP autoSV For patients with central or complex sleep apnea and periodic breathing. Pressure range IPAP: 4 cm to 30 cm H2O Pressure range EPAP: 4 cm to 25 cm H2O Sample Script EPAP min _______cm H2O (4-25 cm) EPAP max_______cm H2O (4-25 cm) PS min ________ cm H2O (0-21 cm) PS max ________ cm H2O (0-21 cm) Max pressure _______ cm H2O (25 cm) Rate ______BPM (auto, 4-30, off) Bi-flex setting ______ (1, 2, 3)

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www.resmed.com

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S9 AutoSet Using ResMed’s time-tested APAP technology, AutoSet continually monitors breathing to always deliver the lowest therapeutic pressure, improving comfort and sleep. Pressure range: 4-20 cm H2O

Sample Script Auto-trial duration________days (0, 3-30) Min. ________cm H2O (4-20 cm) Max.________cm H2O (4-20 cm) A-Flex setting ________(1, 2, 3)

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S9 EliteTM Designed for a more natural breathing experience, the S9 Elite’s enhanced Easy-Breathe technology delivers whisper-quiet therapy from the device and the mask. Pressure range: 4-20 cm H2O

Sample Script Pressure _________cm H2O (4-20 cm) C-flex + setting _________(1, 2, 3)

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S9 VPAPTM S Compact bi-level device designed to deliver effective and comfortable therapy; uses Easy-Breathe motor to make breathing easier for patients with obstructive sleep apnea (OSA), non-compliant CPAP users and those who require additional ventilation support. Pressures:

IPAP 4-25 cm H2O EPAP 3-25 cm H2O CPAP 4-20 cm H2O

Sample Script Mode: q CPAP q S q S/T q T q PC EPAP _______ cm H2O (4-25 cm) (S/T, T, PC modes) IPAP _______ cm H2O (4-25 cm) (S/T, T, PC modes) Rate_______ BPM (off, 1-30) q AVAPS feature: IPAP min _______cm H2O (4-30 cm) (EPAP-IPAP max) IPAP max _______cm H2O (4-30 cm) VT: _______mL (200-1500 mL)

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S9 VPAPTM ST VPAP ST is ResMed’s mid-level noninvasive ventilator designed to treat nondependent patients with respiratory insufficiency, requiring the security of a backup rate (up to 50 bpm), in the hospital or the home. Ideal for noncompliant CPAP patients, the VPAP S features Enhanced Easy-Breathe technology for quiet and comfortable therapy. Maximum Pressure: 25 cm H2O Sample Script Mode: q S/T q S EPAP pressure _______ cm H2O (4-25 cm) IPAP pressure _______ cm H2O (4-25 cm) Mode: q CPAP CPAP pressure _______cm H2O (4-20 cm)

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Rate_______ BPM (off, 1-30) S/T only

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S9 VPAPTM Auto The VPAP Auto is an auto-adjusting bi-level device designed to address the unique needs of noncompliant OSA patients while providing quiet and comfortable therapy. Pressures:

Minimum EPAP 4 cm H2O Maximum IPAP 25 cm H2O

Sample Script Mode: q CPAP q S q S/T q T q PC EPAP _______ cm H2O (4-25 cm) (S/T, T, PC modes) IPAP _______ cm H2O (4-25 cm) (S/T, T, PC modes) Rate_______ BPM (off, 1-30) q AVAPS feature: IPAP min _______cm H2O (4-30 cm) (EPAP-IPAP max) IPAP max _______cm H2O (4-30 cm) VT: _______mL (200-1500 mL)

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S9 VPAPTM Adapt The VPAP Adapt is an adaptive servo-ventilator specifically designed to treat central sleep apnea (CSA) in all its forms while providing quiet and comfortable therapy. The VPAP Adapt algorithm adapts to the patient’s ventilation needs on a breath-by-breath basis, and is synchronized to the patient’s own recent breathing rate and flow pattern to maximize comfort and compliance. Pressure: EPAP adjustable from 4–15 cm H2O Sample Script EPAP min _______cm H2O (4-25 cm) EPAP max_______cm H2O (4-25 cm) PS min ________ cm H2O (0-21 cm) PS max ________ cm H2O (0-21 cm) Max pressure _______ cm H2O (25 cm) Rate ______BPM (auto, 4-30, off) Bi-flex setting ______ (1, 2, 3)

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www.FPHcare.com

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The F&P IconTM The F&P ICON™ Auto CPAP combines advanced auto-adjusting algorithm and SensAwake™ Technology. It delivers ThermoSmart™ technology for more humidity and comfort; auto-adjusting pressure for personalized treatment during sleep; SensAwake™ technology to respond to waking moments; and Info Technologies for flexible data communication options. It can be used as a titration and long-term solution for patients. The flow-based auto-adjusting algorithm detects and effectively responds to flow limitation, hypopnea and apnea. Pressure: Delivers greater than 10cm H2O

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Sample Script Min. ________cm H2O (4-20 cm) Max.________cm H2O (4-20 cm) A-Flex setting ________(1, 2, 3)

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www.respironics.com

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Medicare Coverage Criteria - Oxygen Therapy Home oxygen therapy is reasonable and necessary only if all of the following conditions are met: 1. The treating physician has determined that the patient has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy, and 2. The patient’s blood gas study meets the criteria stated below, and 3. The qualifying blood gas study was performed by a physician or by a qualified provider or supplier of laboratory services, and 4. The qualifying blood gas study was obtained under the following conditions: cut away

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a. If the qualifying blood gas study is performed during an in-patient hospital stay, the reported test must be the one obtained closest to, but no earlier than two days prior to the hospital discharge date, OR b. If the qualifying blood gas study is not performed during an in-patient hospital stay, the reported test must be performed while the patient is in a chronic stable state – i.e. not during a period of acute illness or an exacerbation of their underlying disease, and 5. Alternative treatment measures have been tried or considered and deemed clinically ineffective.

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EverGo • • • •

Up to eight hours of battery life Less than 10 pounds One easy-to-remove patient filter Large oxygen capacity (1050 ml/min)

Sample Script LPM 1 - 6 ________ Patient oxygen desaturations________ Diagnosis______________________Duration _________

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SimplyGo • • • • •

Portable concentrator weighs 10 pounds Offers continuous flow of 2 liters per minute and a pulse dose delivery of up to 6 liters per minute. Has more than twice the oxygen output of any POC weighing 10 pounds or less. Delivers oxygen in the continuous flow, pulse or sleep modes. Battery is immediately accessible and can be easily changed.

Pulse dose setting of 2 Continuous flow at 1 lpm Batteries 1 3.7 2 hours 2 7.4 4 hours 3 11.1 6 hours 4 14.8 8 hours

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Everflo Q Stationary Concentrator • Designed with fewer parts; just two filters • Small, light (31 pounds), easy to transport; fits in trunk of car • 0.5 to 5 liters per minute • 93 percent (+/- 3 percent) concentration at 5 lpm

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Millennium M10 Concentrator • Delivers up to 10 lpm of oxygen • Reduces delivery costs for 5 lpm-and-above oxygen patients

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UltraFill Home Oxygen System •

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Combines stationary oxygen concentrator, filling station and high-capacity 3,000 PSI cylinders to meet needs of wide range of oxygen patients When filling tanks, 3 lpm of oxygen is available with a 5 liter concentrator; up to 7 lpm available with a 10 liter concentrator One-handed cylinder connect/disconnect Patients can stop/restart filling at their convenience Cylinders can be topped off to make partial fills

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LifeChoice Portable Oxygen Concentrator • •

Virtually maintenance free; weighs less than 5 pounds. Can be used 24/7 in auto, active and sleep modes.

A Pulse Wave Delivery System provides oxygen congruent with the patient’s normal inhalation rate so what is delivered, is received. Pulse Wave Delivery along with Auto Mode are the reasons why this device can be used during sleep when other POCs are not effective. Internal battery will last 2 hours on all settings, while the included external battery pack will add an additional 3 hours on all settings providing in combination over 5 hours of mobility using setting of 1, 2 or 3LPM cut away

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Physicians, To refer a patient, complete a referral form and fax to our scheduling department at 800-783-5756.

Please include patient’s insurance information or a photocopy of patient’s insurance card. Our staff will contact the patient within 24 hours to schedule the appointment and obtain any additional information we may need. Once the appointment is scheduled, we will send confirmation with the date and time via fax to your office. Should the patient change or cancel their appointment you will also be notified. If you have questions, please call us at 877-236-8494.

Ph: 877-236-8494 • Fx: 800-783-5756 Email: [email protected] www.comfortsleepservices.net

Ph: 877-236-8494 • Fx: 800-783-5756 Email: [email protected] www.comfortsleepservices.net