Electronic Spirometry for Home Use
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Policy governing prior authorization, medical necessity, and coverage criteria for electronic (home) spirometers for Connecticut Medicaid (HUSKY Health) providers and enrolled patients.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medically necessary indication
Covered when ALL of the following are met
Investigational / Not medically necessary indications
Not covered (investigational) when ANY of the following apply
Home electronic spirometers are considered investigational and not medically necessary for any indication other than lung transplant recipients. The policy bases coverage determinations on the DSS definition of Medical Necessity, and states that clinical evidence is insufficient in peer‑reviewed published literature to support the clinical efficacy of home use for non‑transplant indications.
Electric spirometry performed in the home setting for indications other than lung transplant recipients is not medically necessary. Requests for home use for non‑transplant indications are considered investigational due to insufficient evidence of benefit.
Coding
| E0487 | Spirometer, electronic, includes all accessories |
Provider Actions & Authorization
Prior authorization required; 3-month rental if approved
Prior authorization is required for electric spirometers; if the device is determined to be medically necessary, authorization will be provided for a three-month rental period. Subsequent requests are reviewed under the Durable Medical Equipment (DME) Rent to Purchase policy.
Authorization contingent on medical necessity and active coverage
Authorization is based on medical necessity at the time it is issued and is not a guarantee of payment — payment depends on the member having active coverage and benefits at the time of service.
Required documentation for prior authorization
Submit a fully completed online authorization request, a signed prescription written within the past three months from an enrolled treating physician/APRN/PA, documentation from the treating provider written within the past three months supporting medical need per the Clinical Guideline, and pricing information per the DSS Pricing Policy for MEDS items.
- Fully completed authorization request via online web portal
- Signed prescription dated within the past 3 months from treating physician, APRN, or PA enrolled in CMAP
- Provider documentation dated within the past 3 months supporting medical need as outlined in the Clinical Guideline
- Pricing information per DSS Pricing Policy for MEDS Items
Denial risk: non‑transplant indications are not medically necessary
Requests for an electric spirometer for indications other than lung transplant recipients are considered investigational and are not medically necessary; such requests would be subject to denial.
Background
An electronic spirometer is an instrument that measures the air entering and leaving the lungs to assess lung function. In the home setting, an electric (home) spirometer is used to monitor pulmonary function remotely. HUSKY Health considers home electronic spirometry medically necessary only for lung transplant recipients; for other indications the available peer‑reviewed evidence is judged insufficient to demonstrate clinical efficacy in the home environment.
Definitions
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