DME Policy Updates: Respiratory Assist Devices (RAD) and Transcutaneous Electrical Nerve Simulation (TENS)

Date Issued: 9/6/2019

EmblemHealth has been working to implement enhancements to our durable medical equipment (DME) payment policies. The goal of this enhancement is to implement DME claim payment policies that are consistent with current industry and national standards, and promote correct coding.

Policy Enhancements for Respiratory Assist Devices (RAD), Airway Pressure Devices, and Oral Appliances/Devices

EmblemHealth-enhanced DME medical and payment policies come from this primary source:

  • Local Coverage Determination DMEMAC/J-A, J-B, J-C, J-D/L33718/R-01-01-2017

According to our policy, a bi-level airway pressure device with back-up rate E0471 is not reasonable and necessary if the primary diagnosis is OSA (obstructive sleep apnea).

Background:

Respiratory Assist Devices (RADs) are noninvasive, spontaneous respiratory assistance devices with positive pressure that use a nasal or facial mask interface, creating a seal. An RAD with backup rate has a timed backup feature to deliver the air pressure whenever sufficient spontaneous respiratory efforts fail to occur. This device is not the same as the continuous positive airway pressure (CPAP) devices that are used primarily for patients documented with sleep apnea.

Policy Enhancements for Transcutaneous Electrical Nerve Stimulation (TENS) Supplies

EmblemHealth-enhanced DME medical and payment policies come from this primary source:

  • Local Coverage Determination DMEMAC/J-A, J-B, J-C, J-D/L33802 (A52520)/R-01-01-2019

During the rental of a TENS unit, supplies for the unit are included in the rental allowance; there is no additional allowance for electrodes, lead wires, batteries, etc. If a TENS unit (E0720 or E0730) is purchased, the allowance includes lead wires and one month’s supply of electrodes, conductive paste or gel (if needed), and batteries.

Exception: Exclude A4450 or A4452 billed with modifier AX (Item used with dialysis services), AU (Item used with ostomy), AV (Item used with prosthetic/orthotic), or AW (Item used with surgical dressing).

Background:

A transcutaneous electrical nerve stimulation (TENS) is the use of a non-invasive electric current produced by a device to stimulate the nerve to reduce both acute and chronic pain. The unit is usually connected to the skin using two or more electrodes. A typical battery-operated TENS unit can modulate pulse with frequency and intensity.