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Oxygen |
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Prescription Must Include: |
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- Liter flow
- Diagnosis
- Frequency
- Duration
Example: (02 @ 3LPM for COPD, 24 HPD, lifetime)
| CRITERIA: |
- O2 Saturation results of 88% or less not more than 30 days old
- A Saturation of 89% will qualify with additional diagnosis of:
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OR |
a) Edema resulting from Congestive Heart Failure
b) Cor pulmonale or documented pulmonary hypertension
c) Hematocrit greater than 56% |
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CPAP |
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Prescription Must Not be older than 30 Days and should include: |
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- Pressure
- Heated Humidifier (if desired)
- Type of Mask (if known)
Example: (CPAP @ 10 cmH20 with heated humidifier and nasal pillows)
| CRITERIA: |
- Current (1 year or less) sleep study (polysomnography)
- Minimum recording time of 120 minutes
- A reported Apnea/Hypopnea Index (AHI) of 15 or greater
- An AHI of 5-14 will qualify with an additional diagnosis of:
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OR
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a) Hypertension
b) Ischemic Heart Disease
c) History of stroke
d) Excessive daytime somnolence
e) Impaired cognition
f) Mind disorder |
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BIPAP |
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Prescription Must Not be older than 30 Days and should include: |
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- IPAP & EPAP Pressures
- Heated Humidifiers (if desires)
- Mask Type (if known)
- Statement that patient was unable to tolerate CPAP
Example: (BIPAP @ 59/9 cmH20 with Heated Humidifier, Medium Full Face Mask, Patient unable to tolerate CPAP
| CRITERIA: |
- Same as CPAP (above)
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