Pulmonary Disease

Pulmonary Disease

Pulmonary Disease

LCD Guideline

Pulmonary Disease

The criteria refer to patients with various forms of advanced pulmonary disease who eventually follow a final common pathway for end stage pulmonary disease. (1 and 2 should be present. Documentation of 3, 4, and 5 will lend supporting documentation.):

1. Severe chronic lung disease as documented by both a and b:

a. Disabling dyspnea at rest, poorly or unresponsive to bronchodilators, resulting in decreased functional capacity, e.g., bed to chair existence, fatigue, and cough: (Documentation of Forced Expiratory Volume in One Second (FEV1), after bronchodilator, less than 30% of predicted is objective evidence for disabling dyspnea, but is not necessary to obtain.)

b. Progression of end stage pulmonary disease, as evidenced by increasing visits to the emergency department or hospitalizations for pulmonary infections and/or respiratory failure or increasing physician home visits prior to initial certification. (Documentation of serial decrease of FEV1>40 ml/year is objective evidence for disease progression, but is not necessary to obtain.)

2. Hypoxemia at rest on room air, as evidenced by pO2 ≤55 mmHg; or oxygen saturation ≤88%, determined either by arterial blood gases or oxygen saturation monitors; (These values may be obtained from recent hospital records.) OR Hypercapnia, as evidenced by pCO2 ≥50 mmHg. (This value may be obtained from recent [within 3 months] hospital records.)

3. Right heart failure (RHF) secondary to pulmonary disease (Cor pulmonale) (e.g., not secondary to left heart disease or valvulopathy).

4. Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months.

5. Resting tachycardia >100/min.

Comparative Data

Change in Breathing - Labored, purse lip breathing

Barrel chest noted

Cough noted

Tripod posture

Increase of SOB - Not able to ambulate or handle activity- patient states “I used to be able to walk to the bathroom and back and not be short of breath, now I can’t wait to the bathroom without taking a break.”

Does not sleep in bed anymore (now sleeps in recliner because it’s more comfortable

Change in Activity - Used to go be involved with every activity, now does not attend activities Change in Intake - Patient was eating 100% now only eating 50%

Infection - Pneumonia, bronchitis

Comorbidities - Increase in CHF exacerbation's


Kidney failure




Syncopal Episodes




Weight Gain