What was true on the date of service.
When CMS changes the rule, we keep the old one. Every version since 2015.
“A CPAP, month 3 of a rental, for a Medicare patient in Utah, 84117, on December 20, 2023. Could the supplier bill? What did Medicare allow? Which edits applied? What did the policy require?”
Live for Medicare DME. The rest of Medicare and Medicaid are coming soon, then commercial plans.
curl "https://api.verzi.health/v1/archive/docs/lcd:33718/as-of?date=2024-01-15"~2 hours and ~130 clicks by hand→one search or one API call, with receipts
The API answers this today, with receipts.
Coverage Knowledge Base
Medicare DME policy documents
151 LCDs and Articles. Every section is checked word for word against the archived source.
E0601
Version in force on 2023-12-20: version 48, 2021-09-27 to 2023-12-31.
Version 52 replaced it 12 days later.
JAJBJCJD · Noridian 19003
Utah is DME MAC jurisdiction JD. The LCD's words are the same for all four MACs.
CO-50 The payer found the item not medically necessary. Verzi's summary.
If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not reasonable and necessary.
LCD L33718, version 48, quoted from the archived file.
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Coverage Knowledge Base Every policy word on this page is CMS's own. Verzi adds pins, receipts, and links only.
Medicare DME policy documents
Find a code or a policy
151 LCDs and Articles. Every section is checked word for word against the archived source before it is shown.
| Document | Title | Versions | Effective range |
|---|---|---|---|
| Article A52457 | Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article | 22 | 2015-10-01 to today |
| Article A52458 | Automatic External Defibrillators - Policy Article | 14 | 2015-10-01 to today |
| Article A52459 | Canes and Crutches - Policy Article | 7 | 2015-10-01 to today |
| Article A52460 | Cold Therapy - Policy Article | 6 | 2015-10-01 to today |
| Article A52461 | Commodes - Policy Article | 8 | 2015-10-01 to today |
| Article A52462 | Eye Prostheses - Policy Article | 12 | 2015-10-01 to today |
Coverage Knowledge Base Every policy word on this page is CMS's own. Verzi adds pins, receipts, and links only.
E0601
Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea
CO-50 The payer found the item not medically necessary. CMS's rule for E0601 is in Coverage Indications, Limitations, and/or Medical Necessity. Verzi's summary, a finding aid.
Coverage Indications, Limitations, and/or Medical Necessity
INITIAL COVERAGE:
In this policy, the term PAP (positive airway pressure) device will refer to both a single-level continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up rate (E0470) when it is used in the treatment of obstructive sleep apnea.
An E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A – C are met:
The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to assess the beneficiary for obstructive sleep apnea.
The beneficiary has a sleep test (as defined below) that meets either of the following criteria (1 or 2):
The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,
The AHI or RDI is greater than or equal to 5 and less than or equal 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.
The beneficiary and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.
If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not reasonable and necessary.
An E0470 device is covered for those beneficiaries with OSA who meet criteria A-C above, in addition to criterion D:
An E0601 has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting.
Ineffective is defined as documented failure to meet therapeutic goals using an E0601 during the titration portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings).
If E0470 is billed for a beneficiary with OSA and criteria A-D are not met, it will be denied as not reasonable and necessary.
A bi-level positive airway pressure device with back-up rate (E0471) is not reasonable and necessary if the primary diagnosis is OSA. If an E0471 is billed with a diagnosis of OSA, it will be denied as not reasonable and necessary.
Version history: LCD L33718
Revision history: complete, all versions
▾ R10 · 09/27/2021 · v48
Revision Effective Date: 09/27/2021. CONCURRENT USE OF OXYGEN WITH PAP THERAPY: Removed: “for 5 minutes total (which need not be continuous)” under criterion 4 for overnight oximetry testing for beneficiaries with OSA
01/12/2023 Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates due to updates to National Coverage Determination 240.2.
▸ Receipts for auditors
84117 not on the rural list
UT,84117,"Salt Lake City, UT","Salt Lake City, UT",202304
…
GET /v1/rules/warrant · E0601 · DME · UT · as_of 2023-12-20"provider": { "supplier": { "enrolled_on_dos": true, "src": "provider_enrollment:2023Q4#3a9f…" }, "ordering": { "pecos_on_order_date": true, "src": "pecos:2023Q4#d88c…" }, "npi_valid": true, "src": "nppes:2023-12#2f70…", "licensed": true, "src": "state_license:UT:2023-12#4c1a…", "excluded": false, "src": "leie:2023-12#c07d…", "accredited": true, "src": "dmepos_supplier_dir:2023-12#91be…" }
GET /v1/rules/warrant · E0601 · DME · UT · as_of 2023-12-20"edits": { "ptp": { "pair": ["E0601","A7030"], "value": "no_active_edit", "src": "ncci_ptp_prac:v29.3#c21e…", "match": "none" }, "mue": { "units_max": 1, "mai": 2, "src": "ncci_mue_dme:2023Q4#a733…" } }
GET /v1/rules/warrant · E0601 · DME · UT · as_of 2023-12-20"fee": { "value": 42.91, "column": "Former CBA: Salt Lake City, UT", "cell": { "hcpcs": "E0601", "mod": "RR", "zip": "84117" }, "src": "dmepos_fs:2023Q4#24a1… · Former CBA Fee Schedule File", "resolved_by": { "rurality": { "src": "dmepos_fs:2023Q4#24a1… · Rural ZIP Code File", "rural": false }, "competitive_bid": { "src": "dmepos_fs:2023Q4#24a1… · Former CBA ZIP Code File", "match": "Salt Lake City, UT" } }, "rule": "The ZIP code associated with the permanent address of the beneficiary determines applicability of the adjusted fee schedule amounts in former CBAs.", "rule_src": "CMS transmittal R4242CP (2019) · 42 CFR 414.210(g)(10)", "valid": { "from": "2023-10-01", "to": "2023-12-31" } }
GET /v1/rules/warrant · E0601 · DME · UT · as_of 2023-12-20"policy": { "sources": [ { "role": "NCD", "doc": "ncd:226", "span": [2318,2507], "sha256": "a1d2…" }, { "role": "LCD", "doc": "lcd:33718@v48", "span": [4088,4185], "sha256": "40ff…" }, { "role": "Policy Article", "doc": "article:52467", "span": [1904,2071], "sha256": "f7c9…" }, { "role": "Documentation Article", "doc": "article:55426", "span": [3660,3801], "sha256": "2b8e…" }, { "role": "Claims Manual", "doc": "manual:clm104c20", "span": [61203,61258], "sha256": "9c04…" } ] }
Example Document names, versions, the W1 fee and the L33718 v48 hash are real; other spans and hashes are examples. · What is real in this demo
Example The document names, doc-ids and versions are real. The W1 fee is real: $42.91 for 2023 Q4, the Salt Lake City, UT column of the Former CBA Fee Schedule in CMS's dme23d.zip; the 84117 rows (former CBA 202304, not on the rural list) are read from the same file. The L33718 v48 hash (40fffb11...) is real. Every other dollar, span and hash is an example. The version in force on a date is not typed. It is resolved live by the archive: GET /v1/archive/docs/lcd:33718/as-of?date=2023-12-20. The signed-answer endpoint (/v1/rules/warrant) is live for Medicare DME (API key required); the source archive and as-of resolution are public, no key.
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