Key facts for NCD 240.9
- Benefit category
- Durable Medical Equipment
- Effective date
- 06/09/2025
- Implemented 10/22/2025
- Transmittal
- Transmittal 13374
- Versions published
- 1
- Manual chapter
- 240
- NCD Manual (Pub. 100-03)
TL;DR
NCD 240.9 sets Medicare's national policy for noninvasive positive pressure ventilation (nippv) in the home for the treatment of chronic respiratory failure (crf) consequent to chronic obstructive pulmonary disease (copd) under the benefit category "Durable Medical Equipment", effective 06/09/2025 and implemented 10/22/2025. The Centers for Medicare & Medicaid Services (CMS) will cover in the home a RAD with backup rate feature to deliver high intensity noninvasive ventilation (NIV) as treatment for patients with chronic respiratory failure (CRF) consequent to chronic… It has been revised once since publication and binds every Medicare Administrative Contractor nationally.
Item or service described
A. General
Respiratory Assist Devices (RADs) with bi-level capability, with or without a backup rate feature, are devices that use a non-invasive interface (mask) to deliver a higher level of airway pressure when the patient inhales than when the patient exhales. A backup rate feature on certain RADs enables the device to provide a prespecified respiratory rate if the patient’s spontaneous respiratory rate decreases below a set number.
Compared with RADs, home mechanical ventilators (HMVs) typically have additional ventilatory modes, monitoring, ventilator control, and safety, alarm, and backup power features (batteries).
Indications and limitations of coverage
B. Nationally Covered Indications
I. Respiratory Assist Devices (RADs)
(a) Initial Coverage Criteria
(i) RAD with Backup Rate Feature
The Centers for Medicare & Medicaid Services (CMS) will cover in the home a RAD with backup rate feature to deliver high intensity noninvasive ventilation (NIV) as treatment for patients with chronic respiratory failure (CRF) consequent to chronic obstructive pulmonary disease (COPD). A RAD with backup rate feature is covered in the home for an initial 6-month period for patients with COPD when all the following criteria are met:
• The patient exhibits persistent hypercapnia as demonstrated by PaCO2 ≥ 52 mmHg by arterial blood gas during awake hours while breathing his/her prescribed FiO2; and
• Sleep apnea is not the predominant cause of the hypercapnia (Formal sleep testing is not required if, per the treating clinician, the patient does not experience
sleep apnea as the predominant cause of hypercapnia.); and
• The patient demonstrates one of the following characteristics:
Stable COPD, without increase in or new onset of more than one respiratory symptom (cough, sputum production, sputum purulence, wheezing, or dyspnea) lasting 2 or more days and no change of pharmacological treatment during the 2-week period before initiation of NIV, or
Hypercapnia present for at least 2 weeks post hospitalization after resolution of an exacerbation of COPD requiring acute NIV.
By the end of the initial 6-month period, a RAD with backup rate feature must be utilized as high intensity therapy, defined as a minimum IPAP ≥ 15 cm H2O and backup respiratory rate of at least 14 breaths per minute.
(ii) RAD without Backup Rate Feature
CMS will cover in the home a RAD without backup rate feature for a patient with CRF consequent to COPD who cannot tolerate high intensity NIV or for whom the backup rate
feature is otherwise medically inappropriate. A RAD without backup rate feature is covered in the home for an initial 6-month period for patients with COPD when all of the following criteria are met:
• The patient exhibits hypercapnia as demonstrated by PaCO2 ≥ 52 mmHg by arterial blood gas during awake hours while breathing his/her prescribed FiO2; and
• Sleep apnea is not the predominant cause of the hypercapnia; (Formal sleep testing is not required if, per the treating clinician, the patient does not experience sleep apnea as the predominant cause of hypercapnia).
(iii) RAD Upon Hospital Discharge
CMS will cover in the home a RAD with or without backup rate feature immediately upon hospital discharge for an initial 6-month period for patients with acute on chronic respiratory failure due to COPD, if the patient required either a RAD or ventilator within the 24-hour period prior to hospital discharge and the treating clinician determines that the patient is at risk of rapid symptom exacerbation or rise in PaCO2 after discharge.
(b) Continuing Usage Criteria for a RAD
Patients must be evaluated at least twice within the first year after initially receiving a RAD. Evaluations must occur by the end of the six-month initial coverage period and again during months 7-12.
First evaluation:
By 6 months after receiving initial coverage of a RAD, the treating clinician must establish that usage criteria and clinical outcomes are being met. Specifically, the patient must be determined by a clinician to use the RAD at least 4 hours per 24-hour period, on at least 70% of days in a 30-day period and achieve at least one the following clinical outcomes:
• Normalization ( or
• Stabilization of a rising PaCO2, or
• 20% reduction in PaCO2 from baseline value, or
• Improvement of at least one of the following patient symptoms associated with chronic hypercapnia:
• headache
• fatigue
• shortness of breath
• confusion
• sleep quality
Second evaluation:
Between 7-12 months after initially receiving a RAD, the treating clinician must establish the patient is using the device at least 4 hours per 24-hour period on at least 70% of days in each paid rental month.
Post second evaluation:
The patient must be using the device at least 4 hours per 24-hour period on at least 70% of days in each remaining paid rental month and any month in which accessories/supplies are dispensed.
II. Home Mechanical Ventilators
(a) Initial Coverage Criteria
CMS will cover a home mechanical ventilator (HMV) used in a volume targeted mode as treatment for a patient with chronic respiratory failure (CRF) consequent to chronic
obstructive pulmonary disease (COPD) who exhibits certain clinical characteristics.
(i) An HMV is covered for an initial 6-month period for patients with COPD when all of the following criteria are met:
• The patient exhibits hypercapnia as demonstrated by PaCO2 ≥ 52 mmHg by arterial blood gas during awake hours while breathing his/her prescribed FiO2; and
• Sleep apnea is not the predominant cause of the hypercapnia (Formal sleep testing is not required if, per the treating clinician, the patient does not experience
sleep apnea as the predominant cause of hypercapnia.); and
• The patient demonstrates at least one of the following characteristics:
• Requires oxygen therapy at an FiO2 ≥ 36% or ≥ 4L nasally, or
• Requires ventilatory support for more than 8 hours per 24-hour period, or
• Requires the alarms and internal battery of a HMV, because the patient is unable to effectively breathe on their own for more than a few hours and the unrecognized interruption of ventilatory support is likely to cause a life-threatening condition if the patient or cannot be otherwise alerted as determined by the treating clinician, or
• Per the treating clinician, none of the below are likely to be achieved with consistent use of a RAD with backup rate feature for at least 4 hours per 24-hour period on at least 70% of days because the patient’s needs exceed the capabilities of a RAD as justified by the patient’s medical condition:
• Normalization ( or
• Stabilization of a rising PaCO2, or
• 20% reduction in PaCO2 from baseline value, or
• Improvement of at least one of the following patient symptoms associated with chronic hypercapnia:
• headache
• fatigue
• shortness of breath
• confusion
• sleep quality
(ii) Home Mechanical Ventilator Use Upon Hospital Discharge
CMS will cover in the home an HMV used in a volume targeted mode immediately upon hospital discharge for an initial 6-month period for patients with acute on chronic respiratory failure due to COPD if the patient’s needs exceeded the capabilities of a RAD (with or without backup rate feature) and required usage of a ventilator within the
Text reproduced from the CMS Medicare Coverage Database record for NCD 240.9 version 1. View the original on cms.gov.
Revision history
05/2026 - Transmittal 13756 issued April 28, 2026, is being rescinded and replaced by Transmittal 13808, dated May 29, 2026, to revise the Pub.100-04 Claims Processing Manual (CPM) Table of Contents and chapter section/sub-section number(s), and transmittal that were erroneously misnumbered and revises business requirement 14177 - 04.2. There are no changes to publication 100-03. All other information remains the same. ( TN 13808 ) (CR14177)
04/2026 - Transmittal 13611 issued January 30, 2026, is being rescinded and replaced by Transmittal 13756, dated April 28, 2026, to revise the Claims Processing Manual, Chapter 32, section 413.1 first paragraph to remove verbiage "high intensity" as this terminology only applies to Respiratory Assist Devices (RADs) and not Home Mechanical Ventilator (HMV). There are no changes to publication Pub 100-03. All other information remains the same. ( TN 13756 ) (CR14177)
01/2026 - Transmittal 13374 issued August 21, 2025, is being rescinded and replaced by Transmittal 13611, dated January 30, 2026, to remove HCPCS code E0465 and ICD-10 diagnosis coding from the Claims Processing instructions and adding minor technical edits to the Pub 100-03 manual. This correction also updates the background and policy sections of both Pub. 100-03 and 100-04 and revises Business Requirement (BR) 14177 - 04.1 and removes BRs 14177 - 04.3 and 14177 - 04.4. All other information remains the same. ( TN 13611 ) (CR14177)
08/2025 - The purpose of this Change Request (CR) is to inform contractors that effective June 9, 2025, contractors shall pay claims for Respiratory Assist Device (RADs) with or without a backup rate feature and Home Mechanical Ventilators (HMVs), in the home, as treatment for patients with Chronic Respiratory Failure (CRF) consequent to Chronic Obstructive Pulmonary Disease (COPD). ( TN 13374 ) (CR14177)
How this NCD shows up on remittances
A service denied under a National Coverage Determination returns CARC 50 (not deemed medically necessary) with remark N386 (decision based on an NCD); a denial citing a local policy instead carries N115. Because NCDs bind nationally, the appeal path is documentation that the patient meets the indications above, not a contractor-policy argument.
How QuickIntell applies NCD 240.9
QuickAuth checks the ordered service and diagnosis against NCD and LCD criteria before the encounter, QuickCode validates the diagnosis pairing on the claim, and QuickRCM routes CARC 50 denials with the policy text and the covered-code list attached so the appeal starts with evidence.
Frequently asked questions — NCD 240.9
What does NCD 240.9 cover?
The Centers for Medicare & Medicaid Services (CMS) will cover in the home a RAD with backup rate feature to deliver high intensity noninvasive ventilation (NIV) as treatment for patients with chronic respiratory failure (CRF) consequent to chronic obstructive pulmonary disease (COPD). A RAD with backup rate feature is covered in the home for an initial 6-month period for patients with COPD when all the following… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database.
When did NCD 240.9 take effect?
The current version (1) is effective 06/09/2025, implemented 10/22/2025, published in transmittal 13374. This is the only published version.
Does a Local Coverage Determination override NCD 240.9?
No. A National Coverage Determination binds all Medicare Administrative Contractors; an LCD can only address services or circumstances the NCD leaves open. Claims denied under this NCD typically return CARC 50 with remark N386 (NCD) rather than N115 (LCD).
Sources
Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.
- Medicare Coverage Database NCDs via the CMS Coverage APIVersion API snapshot 2026-09-27 · effective 2026-09-20 · file national-coverage-ncd.jsonSHA-256 a90fadfd264b9ef4…
Disclaimer
This page reproduces the CMS National Coverage Determination text and, for laboratory NCDs, the CMS ICD-10 edit lists, as an operational reference. Coverage decisions depend on the full policy, the claim and the contractor; nothing here is legal, clinical or billing advice. CPT codes are shown as numbers only; CPT descriptors are copyright AMA.