The Centers for Medicare & Medicaid Services (CMS) has finalized its national coverage determination (NCD) for noninvasive positive pressure ventilation (NIPPV) in patients with chronic obstructive pulmonary disease (COPD) who have chronic respiratory failure.
This is the first time Medicare has established national coverage for home mechanical ventilation (HMV) in COPD, and it also expands coverage for respiratory assist devices (RADs).
Effective date: June 9, 2025
Claims payable starting: October 22, 2025
What’s Covered Under the Final NCD
CMS’s final NCD clearly defines which devices are covered for home use in COPD patients with chronic respiratory failure. Coverage now includes several types of respiratory assist devices (RADs) and home mechanical ventilators (HMVs), with criteria that reflect patient needs and clinical indications. Below is a breakdown of what is included under the new policy and the circumstances under which each device may be used.
- Respiratory Assist Devices (RADs) with backup rate feature: Initial 6-month coverage for high-intensity noninvasive ventilation when patients meet defined hypercapnia criteria.
- RADs without a backup rate feature: For patients who cannot tolerate or are inappropriate candidates for a backup rate feature.
- RADs upon hospital discharge: Immediate coverage for patients transitioning from acute to chronic respiratory failure.
- Home Mechanical Ventilators (HMVs): National coverage for COPD patients who meet defined criteria, including oxygen dependence, more than 8 hours per day of support, or the need for alarms/battery backup.
Continued coverage requirements
To maintain coverage, Medicare requires that patients be evaluated at least twice during the first year.
The first evaluation must occur by six months, and the second evaluation between seven and twelve months.
Providers should ensure ongoing documentation of patient compliance, clinical progress, and any necessary adjustments to therapy.
CMS Guidance for DME MACs
CMS has directed DME Medicare Administrative Contractors (DME MACs) to implement the final NCD, which takes effect on June 9, 2025. Claims for qualifying RADs and HMVs will be payable starting October 22, 2025, giving providers a clear timeline for coverage and reimbursement under the new policy.
- Effective date: June 9, 2025
- Implementation date: October 22, 2025 (claims for qualifying RADs and HMVs payable starting this date)
Conforming updates have been added to NCD Manual Section 240.9.
What DME Providers Should Do Now
With the new NCD taking effect, providers should take proactive steps to ensure compliance.
Key actions include updating documentation, educating referral sources, managing inventory, training staff, and coordinating closely with patients. Let’s talk about it.
Update Your Documentation Processes
- Ensure arterial blood gas testing (PaCO2 ≥ 52 mmHg) and clinician notes clearly document patient eligibility.
- Track patient evaluations: the first must occur by six months, and the second between seven and twelve months.
Educate Your Referral Sources
- Inform pulmonologists and hospital discharge planners of new coverage criteria.
- Provide checklists for qualifying patients (hypercapnia, stable COPD, post-hospitalization, etc.).
Adjust Your Inventory and Supply Chains
- Stock RADs with and without backup features, as well as HMVs that meet Medicare criteria.
- Confirm availability of multiple interface options (oronasal/night masks and daytime masks).
Train Your Team
- Billing teams: Ensure correct coding and claim submission under the new coverage.
- Clinical teams: Verify ongoing usage and patient outcomes to secure continued coverage.
Coordinate with Patients
- Educate patients on proper usage (≥ 4 hours/day on at least 70% of days).
- Reinforce the importance of follow-up evaluations for continued coverage.
What Does This Mean for the Industry?
The final NCD represents a significant shift for the home respiratory care landscape.
Expanded coverage means more COPD patients will have access to noninvasive ventilation at home, improving their quality of life.
For providers, the final NCD represents more responsibilities—thorough documentation, regular follow-up evaluations, and careful monitoring will be critical to maintaining coverage. Even so, providers are positioned to play an even stronger role in coordinating care with clinicians, reinforcing their value in the broader healthcare ecosystem.
For more insights and updates on the industry, check out:
- How AI and Automation are Transforming the Future of Patient Communication
- What the HIPAA NPRM Means for DME Providers—and How to Prepare Now
- Operations Management: A Bottom-Line Solution
Prepare Your Team for the 10/22 Implementation Date
Now is the time to review your internal processes and communicate with referral sources. Preparing in advance will help ensure smooth implementation when claims are payable on October 22, 2025.
And if you need support, reach out. We’re here to guide your team with billing, compliance, and operational expertise ahead of the new NCD requirements.