Pulmonary HTN (Hypertension) Infusion Guidelines
Therapies:
- Epoprostenol
- Treprostini
Qualifying Diagnoses:
- Primary pulmonary hypertension
- Pulmonary hypertension, secondary to:
- connective tissue disease
- thromboembolic disease of the pulmonary arteries
- human immunodeficiency virus (HIV) infection
- cirrhosis
- diet
- drugs
- congenital left to right shunts, etc.
- Pulmonary hypertension progressed despite maximal medical and/or surgical treatment of the identified condition.
- Mean pulmonary artery pressure is greater than 25 mm Hg at rest or greater than 30 mm Hg with exertion
- Significant symptoms from the pulmonary hypertension (i.e., severe dyspnea on exertion, and either fatigability, angina, or syncope)
- human immunodeficiency virus (HIV) infection
- Treatment with oral calcium channel blocking agents has been tried and failed or has been considered and ruled out
- NOT qualifying:
- Pulmonary hypertension secondary to pulmonary venous hypertension such as:
- left sided atrial or ventricular disease
- left sided valvular heart disease
- disorders of the respiratory system, etc.
- Pulmonary hypertension secondary to pulmonary venous hypertension such as:
Chartwell reviews all eligible Medicare patients for infusion qualification based on the Noridian LCD found at: External Infusion Pumps LCD and PA (noridianmedicare.com). Noridian has the most current and up to date information. Please refer to the Noridian site for clarification of any content on this site.
Some therapies will have fill and total dose limitations with each qualifying diagnosis. Some therapies will require an electronic external infusion pump, while others will prohibit use of an electronic pump based on the LCD. Medicare covers home infusion under their external infusion pump coverage within the Durable Medical Equipment benefit.
For qualification, provider documentation requires diagnostic testing to support diagnosis for all therapies requiring Medicare qualification. Additionally:
Some therapies will have fill and total dose limitations with each qualifying diagnosis. Some therapies will require an electronic external infusion pump, while others will prohibit use of an electronic pump based on the LCD. Medicare covers home infusion under their external infusion pump coverage within the Durable Medical Equipment benefit.
For qualification, provider documentation requires diagnostic testing to support diagnosis for all therapies requiring Medicare qualification. Additionally:
- The patient must be eligible for a defined Medicare benefit category.
- Therapy must be reasonable and necessary for the diagnosis and supported in medical documentation.
- The case must meet all other applicable Medicare statutory and regulatory requirements.