Medicare Guidelines for Non-Cancer

PULMONARY DISEASE

  1. Severe chronic lung disease documented by A and B

      A. Disabling Dyspnea at rest, poorly or unresponsive

      to bronchodilators, resulting in decreased functional

      capacity.

 

*Documentation of forced expiratory volume in one second

(FEV1) after bronchodilator, less than 30% predicated.*

 

     B. Progression of end-stage pulmonary disease, as

     evidenced by prior increasing visits to the emergency

     department or prior hospitalizations for pulmonary

     infections / respiratory failure

 

*Documentation of serial decrease in FEV1 on serial

testing of > 40 ml per year.*

 

2. Hypoxemic at rest on room air, as evidenced by:

·        pO2, < 55 mm Hg or

·        O2 saturation 88%

·        Hypercapnia (pCO2 50 mm Hg)

 

Supportive Documentation

 

       1. Cor pulmonale and right heart failure (RHF)

       2. Progressive weight loss > than 10% over preceding

           6 months

       3. Resting tachycardia > 100/mm

 

     ICD-9 Codes that support medical necessity:

     Diagnoses for pulmonary disease, which leads to

     end-stage pulmonary disease, will be accepted.