Respiratory HME Qualification Guide

Oxygen Therapy

  1. Patient demographic information

  2. Documentation in patient chart outlining basis for oxygen order, with standard script from physician having patient ID, order date, oxygen liter flow, and timespan.

  3. At least one of the following qualifications must be satisfied for a patient's oxygen therapy to be approved by insurance:

  4. SaO2/SpO2 ≤ 88% , documented at rest, with exertion, and room air.

CPAP & BiPAP

  1. Patient demographic information

  2. Physician-ordered sleep study and documentation in patient record of at least one symptom such as: daytime drowsiness, cognitive problems, psychological conditions, sleeplessness, high BP, cardiac disease, or stroke history.

  3. If sleep evaluation shows positive findings based on CMS's endorsed apnea-hypopnea criteria, physician should provide standardized order with patient name, date, and CPAP specifications, ideally AutoCPAP. Non-AutoCPAP settings necessitate an additional CPAP titration exam.

  4. BiPAP can only be provided if CPAP has been ruled out, based on chart notes detailing either a previous failed CPAP attempt for the patient or why CPAP is insufficient for meeting the patient's requirements.

Non-Invasive Ventilation (sometimes referred to as AVAPS, IVAPS or Trilogy)

  • Patient Demographic Information 

  • At least one of the following qualifications must be documented in patient chart within last 12 months detailing:

    • Chronic Respiratory Failure + COPD (Requires: ABG with PaCO2 > 45 mmHg or PFT with FEV1 < 50% or FVC < 50%)

    • Chronic Respiratory Failure + Restrictive Thoracic or Neuromuscular Disorder (Requires: ABG with PaCO2 > 45 mmHg or PFT with either FVC < 50% or MIP < 60 cmH2O)

    • Chronic Respiratory Failure due to Obesity Hypoventilation Syndrome (Requires: PFT with FVC less than 50% and FEV1/FVC ratio greater than 70%)

  • Mechanical ventilator order including: patient name; order date; specific ventilator model, mode, and settings; and required supplies.

  • BiPAP ST should be ruled out due to either having failed previously for the patient, or documentation explaining why BiPAP ST cannot meet the patient's needs.

  • Documentation in patient chart that indicates the patient has a life-threatening condition and is at significant risk of harm without mechanical ventilation.

Medication Nebulizer

  1. Patient demographic information

  2. Documentation in patient chart on the rationale for prescribing nebulizer therapy, with accompanying ICD-10 codes J41.0 through J70.9 plus the prescribed nebulizer medication, alongside a physician order with the patient’s name and order date.