Does Medicare a Zephyr Valve? 

Everyone knows that breathing is vital for survival, but you may be surprised to learn just how little oxygen the human body needs to live. Research has shown that humans can survive in environments where the air is only made up of 19% oxygen. Even below this level, the ability to stay alive is still possible. Although this is interesting scientifically, there is a big difference between surviving and thriving. Just because you can live with minimal oxygen does not mean such conditions make for an enjoyable existence.

Unfortunately, several health conditions, including emphysema, can impact lung function. People with emphysema can still breathe and function, but if you’re a senior with emphysema or chronic obstructive pulmonary disease (COPD), you already know that it can be challenging to do everyday tasks without taking breaks or using supplemental oxygen.

Treatment options for emphysema

Treatment options for emphysema are limited due to the nature of the disease. After years of damage, the lungs’ alveoli collapse in emphysema cases. The alveoli are tiny sacs in the lungs that fill with oxygen when you breathe. When emphysema sets in, the alveoli are replaced with larger sacs that reduce the lungs’ surface area. This reduces the amount of oxygen that can be taken in with each breath.

In treating the condition, temporary inhalation medications may improve lung function to a degree, but because emphysema causes a physical change in the way the lungs operate, these treatment options are unable to reverse the condition. As mentioned above, supplemental oxygen may also be an option to help healthy parts of the lungs operate at maximum efficiency, but this treatment option requires someone with emphysema to carry around an oxygen supply.

A newer treatment option is the Zephyr valve. This tiny valve is inserted into the airways to reduce pressure on the diaphragm. The procedure to implant a Zephyr valve is considered minimally invasive and is an FDA-approved treatment option for emphysema that may benefit some people where other treatment options are less efficient.

Does Medicare cover a Zephyr valve?

Medicare coverage may provide benefits for Zephyr valve implantation, but the Centers for Medicare & Medicaid Services (CMS) has not released an official coverage determination yet for the Zephyr valve procedure specifically. As a result, cases of need are evaluated individually, but like with all things under Medicare consideration, coverage is typically available if it can be demonstrated that a procedure is medically necessary.

If you are a Medicare recipient who is facing emphysema or COPD, you’re encouraged to work closely with your doctor to file any Medicare benefit claims for a Zephyr valve procedure. With your doctor’s help and proper documentation, you stand a better chance of getting the procedure approved.

Coverage options for Zephyr valve implantation

If approved, Medicare benefits cover Zephyr valve implantation in several ways. First, the actual procedure itself is covered by Medicare Part B. This is outpatient coverage, and it is used to cover medical services like doctor visits and surgery. Although your Zephyr valve procedure may occur in a hospital, Medicare Part B pays for the procedure.

With that said, hospital care is covered through Medicare insurance under Part A. Some people who require Zephyr valve implantation must spend a few days admitted to a hospital or skilled nursing facility after the procedure. In these cases, Medicare benefits under Part A will cover 60 days in a hospital or 20 days in a skilled nursing facility.

If medications are prescribed for aftercare following the implantation of a Zephyr valve, Medicare Part D may provide coverage. Medicare Part D is prescription drug coverage, and it applies to medications that can be picked up from retail pharmacies and taken at home. Covered medications are listed in a plan’s formulary, so you must consult your plan’s materials to see if your drugs are covered.

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