Devices Used for the Treatment of Sleep Apnea in Adults

Policy ID: E-20-040

Section: Durable Medical Equipment

Effective Date: April 15, 2019

Revised Date: May 12, 2025

Revision Effective Date: July 07, 2025

Last Reviewed: May 13, 2025

Applies To: Commercial and Medicaid Expansion

Description

Positive airway pressure (PAP) devices are indicated for use in the treatment of sleep apnea. PAP devices may improve quality of life in individuals with sleep apnea in adults. Close follow-up for PAP device usage and problems in individuals with sleep apnea by appropriately trained health care providers is indicated to establish effective utilization patterns and remediate problems if needed.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; or

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Auto-titrating Positive Airway Pressure (APAP) or Continuous Positive Airway Pressure (CPAP)

Policy Application

An APAP device or CPAP device may be considered medically necessary for the treatment of obstructive sleep apnea (OSA) in adults and covered as durable medical equipment when the following criteria are met:

APAP

APAP during a two (2) week trial to initiate and titrate CPAP in adult individuals with a confirmed diagnosis of OSA.

CPAP

Individuals have confirmed diagnosis of OSA (confirmed via a positive facility-based polysomnogram (PSG) or with a positive home/portable sleep test); and
Apnea/hypopnea index (AHI) as follows:
- Greater than or equal to 15 events per hour of sleep in an asymptomatic individual; or
- Greater than five (5) events per hour of sleep in a symptomatic individual (e.g., sleepiness, fatigue and inattention); or
- Signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses).

APAP or CPAP devices not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Code

E0601

Bi-level Positive Airway Pressure(BiPAP) without back-up rate

Policy Application

BiPAP without back-up rate may be considered medically necessary for the treatment of OSA in adults and may be considered as durable medical equipment when the following criteria are met:

Individuals have confirmed diagnosis of OSA (confirmed via a positive facility-based PSG or with a positive home/portable sleep test); and
AHI greater than or equal to 15 events per hour of sleep in an asymptomatic individual, or
- Five (5) events per hour of sleep in a symptomatic individual (e.g., sleepiness, fatigue and inattention); or
- Signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses) and ONE (1) of the following:
  - Individual has- failed a prior trial of CPAP. If the individual is uncomfortable or intolerant of high pressures on CPAP; the individual may be tried on BiPAP. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the individual may be switched to BiPAP; or
  - For whom BiPAP is found to be more effective in the sleep lab.

BiPAP without back-up rate devices not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Code

E0470

BiPAP with back-up rate

Policy Application

A BiPAP device with back-up rate is considered not medically necessary with the primary diagnosis of OSA, in adults.

Procedure Code

E0471

Central Sleep Apnea

A positive airway pressure device (CPAP, BPAP-ST,) may be considered medically necessary for the first three (3) months of therapy for those individuals with central sleep apnea (CSA) that have had an attended polysomnogram, performed on stationary equipment and meet ALL of the following criteria:

The diagnosis of CSA; and
The exclusion of obstructive sleep apnea (OSA) as the predominant cause of sleep-associated hypoventilation; and
For BPAP-ST, the ruling out of CPAP as effective therapy if OSA is a component of the sleep-associated hypoventilation; and
Significant improvement of the sleep-associated hypoventilation with the use of either PAP device on the settings that will be prescribed for initial use at home, while breathing the individual's prescribed FIO2.

Intra-Oral Appliances

Intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) may be considered medically necessary in adult individuals with OSA when ALL of the following criteria are met:

AHI greater than or equal to 15 events per hour of sleep in an asymptomatic individual or greater than five (5) events per hour of sleep in a symptomatic individual (e.g., sleepiness, fatigue, and inattention) or signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses); and
A trial with CPAP has failed, is contraindicated, or the individual prefers alternate therapy; and
The device is prescribed by a treating physician; and
The device is custom fitted by qualified dental personnel; and
There is absence of temporomandibular dysfunction or periodontal disease.

Intra-oral devices not meeting the criteria as indicated in this policy are considered not medically necessary.

There are many different types of appliances that basically fit into one of two (2) categories, tongue retaining appliances, and mandibular repositioning appliances. Payment may be made for one (1) appliance. Additional appliances should be denied as not medically necessary. However, replacement of an oral appliance may be considered medically necessary when the item has reached the end of its five (5) year reasonable use lifetime, or when wear and tear renders the item non-functioning and not repairable, and the item is no longer under warranty. It will be necessary for the provider to submit medical records and/or additional documentation to determine coverage in this situation.

Over the counter (OTC) or prefabricated intra-oral appliances to treat OSA are not considered to be appropriate therapy for OSA in any clinical situation and, therefore, are non-covered.

Note: CPAP has been shown to have greater effectiveness than oral appliances in general. This difference in efficacy is more pronounced for individuals with severe OSA, as oral appliances have been shown to be less efficacious in individuals with severe OSA than they are in individuals with mild-moderate OSA. Therefore, it is particularly important that individuals with severe OSA should have an initial trial of CPAP and that all reasonable attempts are made to continue treatment with CPAP, prior to the decision to switch to an oral appliance.

Procedure Codes

D9954

D9955

E0485

E0486

K1027

Nasal Expiratory Positive Airway Pressure (EPAP)

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Nasal EPAP devices (e.g., Provent™, Theravent™) are considered experimental/investigational, and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

Procedure Code

E1399

Oral Pressure Therapy (OPT)

OPT devices (e.g., Winx® Sleep Therapy System) are considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.

Procedure Codes

A7002

A7047

E0600

Daytime Electrical Stimulation Devices

Policy Application

Daytime electrical stimulation (eXciteOSA) of the tongue is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-review literature.

Procedure Codes

E0490

E0491

E0492

E0493

Sleep Positioning Trainer

Policy Application

Sleep positioning trainer with vibration is considered experimental/investigational and, therefore, non-covered because the safety and/or effectiveness of this service cannot be established by review of the available published peer-review literature.

Procedure Code

E0530

Payment for the rental of a PAP device

Policy Application

Payment will be made for the rental of a PAP device for the first three (3) months (rental period) from the original start date of therapy, when the above clinical criteria are met. Device expenses incurred during the first three (3) months of rental will be applied to the purchase price. Payment will be made for the purchase of the device when BOTH of the following criteria are met:

Documented compliance with objective findings (i.e., compliance chip, telemonitoring, computer software) of device usage for three (3) consecutive months; and
The individual is experiencing success in treatment.

Compliance monitoring equipment for CPAPs, APAPs, or BiPAPs (e.g., smart card, compliance chip, tele monitoring, and computer software) is considered an integral component of the function of the device and is not eligible for separate reimbursement.

Continued use beyond the first three (3) months of therapy

The medical records must also document objective findings of compliance information, (i.e. compliance chip, telemonitoring, computer software), confirming that the member has been adhering to PAP therapy and is benefiting from its use. Adherence to therapy is defined as use of PAP greater than or equal to four (4) hours per night on 70% of nights during a consecutive 30-day period anytime during the first three (3) months of initial usage.

Replacement of PAP Devices

Replacements of PAP devices for members with an existing diagnosis of OSA do not need a compliance chip if documentation of previous compliance, (i.e., compliance chip, telemonitoring, computer software), has been confirmed in the medical record.

Procedure Codes

E0470

E0471

E0601

Cleaning Devices

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

PAP devices have directions from the manufacturing company included for cleaning. CPAP sanitizer cleaning systems are considered convenience items and therefore non-covered.

Procedure Code

E1399

Accessories

Policy Application

Accessories used with a positive airway pressure (PAP) device may be considered medically necessary when the criteria for the device are met. If the criteria are not met, the accessories are considered not medically necessary.

Liners

Liners are not interfaces for use with a PAP mask. Liners are products placed between the individual's skin and the PAP mask interface and are made of cloth, silicone or other materials. These are not considered 'interfaces' as defined in this policy.

Liners must not be billed as replacement interface for a PAP mask or as a replacement cushion for use on nasal mask interface.

A liner used in conjunction with a PAP mask is considered a comfort and convenience item and is considered a non-covered item or service.

There is no additional payment for liners used with a PAP mask.

A replacement cushion/pillow is not billable when supplying an ongoing replacement of the frame with cushion/pillow. Billing for each individual component is considered unbundling of these supplies. The allowance of a replacement mask interface every month is considered an exception and documentation should support the medical necessity.

Note: See the table below for the usual maximum amount of accessories considered to be medically necessary. A replacement device is not covered if due to misuse or abuse and is considered a non-covered service.

Accessories

Policy Application

A4604

1 per 3 months

Tubing with integrated heating element for use with positive airway pressure device

A7027

1 per 3 months

Combination oral/nasal mask, used with continuous positive airway pressure device, each

A7028

2 per 1 month

Oral cushion for combination oral/nasal mask, replacement only, each

A7029

2 per 1 month

Nasal pillows for combination oral/nasal mask, replacement only, pair

A7030

1 per 3 months

Full face mask used with positive airway pressure device, each

A7031

1 per 1 month

Face mask interface, replacement for full face mask, each

A7032

2 per 1 month

Cushion for use on nasal mask interface, replacement only, each

A7033

2 per 1 month

Pillow for use on nasal cannula type interface, replacement only, pair

A7034

1 per 3 months

Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap

A7035

1 per 6 months

Headgear used with positive airway pressure device

A7036

1 per 6 months

Chinstrap used with positive airway pressure device

A7037

1 per 3 months

Tubing used with positive airway pressure device

A7038

2 per 1 month

Filter, disposable, used with positive airway pressure device

A7039

1 per 6 months

Filter, non-disposable, used with positive airway pressure device

A7044

1 per 3 months

Oral interface used with positive airway pressure device, each

A7045

1 per 3 months

Exhalation port with or without swivel used with accessories for positive airway pressure devices, replacement only

A7046

1 per 6 months

Water chamber for humidifier, used with positive airway pressure device, replacement, each

**Allowing for a three (3) month supply *Allows for a 10-day delivery before run-out

Quantities of supplies greater than those identified as the usual maximum amounts will be denied as not medically necessary.

Regardless of utilization, a supplier must not dispense more than a three (3) month quantity at a time.

Either a heated humidifier or a non-heated humidifier is eligible for use with a covered PAP device when prescribed by the treating physician to meet the needs of the individual.

Procedure Codes

A4604

A7027

A7028

A7029

A7030

A7031

A7032

A7033

A7034

A7035

A7036

A7037

A7038

A7039

A7044

A7045

A7046

A7049

A9270

E0561

E0562

E1399

S8186

Diagnosis Codes

Covered sleep apnea Diagnosis Codes for Procedure Code E0601

G47.31

G47.32

G47.33

G47.34

G47.35

G47.36

G47.37

Non-Covered Diagnosis Code for Procedure Code E0471

G47.33

Professional Statements and Societal Positions Guidelines

According to the American Academy of Sleep Medicine (AASM) obstructive sleep apnea (OSA) in adults is defined as either:

More than fifteen (15) apneas, hypopneas, or respiratory effort related arousals (RERAs) per hour of sleep (i.e., an apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) greater than fifteen (15) events/hr.) in an asymptomatic individual; or
More than five (5) apneas, hypopneas, or RERAs per hour of sleep (i.e., an AHI or RDI greater than five (5) events per hour) in an individual with symptoms (e.g., sleepiness, fatigue, and inattention), or signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses). More than 75 percent of the apneas or hypopneas must have an obstructive pattern.

The AASM classifies mild, moderate and severe OSA as:

Mild OSA: AHI of 5-15
- Involuntary sleepiness during activities that require little attention, such as watching TV or reading.
Moderate OSA: AHI of 15-30
- Involuntary sleepiness during activities that require some attention, such as meetings or presentations.
Severe OSA: AHI of greater than 30
- Involuntary sleepiness during activities that require more active attention, such as talking or driving.

Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy (2015)

Recommendations:

We recommend that sleep physicians prescribe oral appliances, rather than no therapy, for adult individuals who request treatment of primary snoring (without obstructive sleep apnea). (STANDARD)
When oral appliance therapy is prescribed by a sleep physician for an adult individual with obstructive sleep apnea, we suggest that a qualified dentist use a custom, titratable appliance over non-custom oral devices. (GUIDELINE)
We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult individuals with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. (STANDARD)
We suggest that qualified dentists provide oversight- rather than no follow-up-of oral appliance therapy in adult individuals with obstructive sleep apnea, to survey for dental-related side effects or occlusal changes and reduce their incidence. (GUIDELINE)
We suggest that sleep physicians conduct follow-up sleep testing to improve or confirm treatment efficacy, rather than conduct follow-up without sleep testing, for individuals fitted with oral appliances. (GUIDELINE)
We suggest that sleep physicians and qualified dentists instruct adult individuals treated with oral appliances for obstructive sleep apnea to return for periodic office visits- as opposed to no follow-up-with a qualified dentist and a sleep physician. (GUIDELINE).

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Annual Review-no changes

Internal Medical Policy Committee 11-19-2020

Added Professional Statement and statement regarding cleaning devices.

Internal Medical Policy Committee 9-21-2021 Coding update- Effective October 01, 2021

Added new procedure code K1027.

Internal Medical Policy Committee 11-23-2021

Revised the way the not medically necessary statements were written; and
Added Daytime electrical stimulation (eXciteOSA) of the tongue.

Internal Medical Policy Committee 3-23-2022 Coding update - E ffective April 01, 2022

Added new procedure codes K1028; & K1029

Internal Medical Policy Committee 3-23-2023 Coding update - Effective April 01, 2023

Added new procedure code A7049.

Internal Medical Policy Committee 5-23-2023 Revision with Coding update - Effective July 03, 2023

Added new statement for new section Sleep Positioning Trainer; and
Added procedure code K1001; and
Added procedure codes A7031; and A7032.

Internal Medical Policy Committee 7-26-2023 Revision - Effective September 04, 2023

Updated wording throughout policy

Internal Medical Policy Committee 11-15-2023 Coding - Effective October 01, 2023

Added procedure codes E0490; and E0491.

Internal Medical Policy Committee 1-16-2024 Coding updated - Effective January 01, 2024

Removed procedure codes K1001; K1028; and K1029; and
Added procedure codes D9954; D9955; E0492; E0493 and E0530.

Internal Medical Policy Committee 5-14-2024-Revision- Effective July 01, 2024

Removal of statement regarding PAP device rental period; and
Added Policy Application.

Internal Medical Policy Committee 7-16-2024 Revision - Effective September 02, 2024

Added statement 'Intra-oral devices do not meet the above criteria if there is a signed affidavit refusing CPAP treatment and therefore considered not medically necessary'.

Internal Medical Policy Committee 3-11-2025 Revision - Effective May 05, 2025

Updated Policy Application; and
Removed statement: 'However, if the member is found to be using the PAP device as directed and is achieving the desired results, the DME supplier must contact the individual's physician near the end of the rental period and ask the doctor to prescribe the purchase of the device. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service.'

Internal Medical Policy Committee 5-13-2025 Revision - Effective July 07, 2025

Added statement 'or the individual prefers alternate therapy' to the intra-oral appliances section; and
Updated Professional Statements; and
Removed section under Payment for the rental of a PAP device

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: E-20-039

Section: Durable Medical Equipment

Effective Date: April 15, 2019

Revised Date: February 28, 2025

Revision Effective Date: May 05, 2025

Last Reviewed: March 11, 2025

Archived Date: July 07, 2025

Applies To: Commercial and Medicaid Expansion

Description

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

Auto-titrating Positive Airway Pressure (APAP) or Continuous Positive Airway Pressure (CPAP)

Policy Application

APAP

APAP during a two (2) week trial to initiate and titrate CPAP in adult individuals with a confirmed diagnosis of OSA.

CPAP

Individuals have confirmed diagnosis of OSA (confirmed via a positive facility-based polysomnogram (PSG) or with a positive home/portable sleep test); and
Apnea/hypopnea index (AHI) as follows:
- Greater than or equal to 15 events per hour of sleep in an asymptomatic individual; or
- Greater than five (5) events per hour of sleep in a symptomatic individual (e.g., sleepiness, fatigue and inattention); or
- Signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses).

APAP or CPAP devices not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Code

E0601

Bi-level Positive Airway Pressure(BiPAP) without back-up rate

Policy Application

BiPAP without back-up rate may be considered medically necessary for the treatment of OSA in adults and may be considered as durable medical equipment when the following criteria are met:

Individuals have confirmed diagnosis of OSA (confirmed via a positive facility-based PSG or with a positive home/portable sleep test); and
AHI greater than or equal to 15 events per hour of sleep in an asymptomatic individual, or
- Five (5) events per hour of sleep in a symptomatic individual (e.g., sleepiness, fatigue and inattention); or
- Signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses) and ONE (1) of the following:
  - Individual has- failed a prior trial of CPAP. If the individual is uncomfortable or intolerant of high pressures on CPAP; the individual may be tried on BiPAP. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the individual may be switched to BiPAP; or
  - For whom BiPAP is found to be more effective in the sleep lab.

BiPAP without back-up rate devices not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Code

E0470

BiPAP with back-up rate

Policy Application

A BiPAP device with back-up rate is considered not medically necessary with the primary diagnosis of OSA, in adults.

Procedure Code

E0471

Central Sleep Apnea

The diagnosis of CSA; and
The exclusion of obstructive sleep apnea (OSA) as the predominant cause of sleep-associated hypoventilation; and
For BPAP-ST, the ruling out of CPAP as effective therapy if OSA is a component of the sleep-associated hypoventilation; and
Significant improvement of the sleep-associated hypoventilation with the use of either PAP device on the settings that will be prescribed for initial use at home, while breathing the individual's prescribed FIO2.

Intra-Oral Appliances

AHI greater than or equal to 15 events per hour of sleep in an asymptomatic individual or greater than five (5) events per hour of sleep in a symptomatic individual (e.g., sleepiness, fatigue, and inattention) or signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses); and
A trial with CPAP has failed or is contraindicated; and
The device is prescribed by a treating physician; and
The device is custom-fitted by qualified dental personnel; and
There is absence of temporomandibular dysfunction or periodontal disease.

Intra-oral devices not meeting the criteria as indicated in this policy are considered not medically necessary.

Intra-oral devices do not meet the above criteria if there is a signed affidavit refusing CPAP treatment and therefore considered not medically necessary.

Over the counter (OTC) or prefabricated intra-oral appliances to treat OSA are not considered to be appropriate therapy for OSA in any clinical situation and, therefore, are non-covered.

Procedure Codes

D9954

D9955

E0485

E0486

K1027

Nasal Expiratory Positive Airway Pressure (EPAP)

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Procedure Code

E1399

Oral Pressure Therapy (OPT)

Procedure Codes

A7002

A7047

E0600

Daytime Electrical Stimulation Devices

Policy Application

Procedure Codes

E0490

E0491

E0492

E0493

Sleep Positioning Trainer

Policy Application

Procedure Code

E0530

Payment for the rental of a PAP device

Policy Application

Documented compliance with objective findings (i.e., compliance chip, telemonitoring, computer software) of device usage for three (3) consecutive months; and
The individual is experiencing success in treatment.

Continued use beyond the first three (3) months of therapy

Replacement of PAP Devices

Procedure Codes

E0470

E0471

E0601

Cleaning Devices

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

PAP devices have directions from the manufacturing company included for cleaning. CPAP sanitizer cleaning systems are considered convenience items and therefore non-covered.

Procedure Code

E1399

Accessories

Policy Application

Liners

Liners must not be billed as replacement interface for a PAP mask or as a replacement cushion for use on nasal mask interface.

A liner used in conjunction with a PAP mask is considered a comfort and convenience item and is considered a non-covered item or service.

There is no additional payment for liners used with a PAP mask.

Accessories

Policy Application

A4604

1 per 3 months

Tubing with integrated heating element for use with positive airway pressure device

A7027

1 per 3 months

Combination oral/nasal mask, used with continuous positive airway pressure device, each

A7028

2 per 1 month

Oral cushion for combination oral/nasal mask, replacement only, each

A7029

2 per 1 month

Nasal pillows for combination oral/nasal mask, replacement only, pair

A7030

1 per 3 months

Full face mask used with positive airway pressure device, each

A7031

1 per 1 month

Face mask interface, replacement for full face mask, each

A7032

2 per 1 month

Cushion for use on nasal mask interface, replacement only, each

A7033

2 per 1 month

Pillow for use on nasal cannula type interface, replacement only, pair

A7034

1 per 3 months

Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap

A7035

1 per 6 months

Headgear used with positive airway pressure device

A7036

1 per 6 months

Chinstrap used with positive airway pressure device

A7037

1 per 3 months

Tubing used with positive airway pressure device

A7038

2 per 1 month

Filter, disposable, used with positive airway pressure device

A7039

1 per 6 months

Filter, non-disposable, used with positive airway pressure device

A7044

1 per 3 months

Oral interface used with positive airway pressure device, each

A7045

1 per 3 months

Exhalation port with or without swivel used with accessories for positive airway pressure devices, replacement only

A7046

1 per 6 months

Water chamber for humidifier, used with positive airway pressure device, replacement, each

**Allowing for a three (3) month supply *Allows for a 10-day delivery before run-out

Quantities of supplies greater than those identified as the usual maximum amounts will be denied as not medically necessary.

Regardless of utilization, a supplier must not dispense more than a three (3) month quantity at a time.

Either a heated humidifier or a non-heated humidifier is eligible for use with a covered PAP device when prescribed by the treating physician to meet the needs of the individual.

Procedure Codes

A4604

A7027

A7028

A7029

A7030

A7031

A7032

A7033

A7034

A7035

A7036

A7037

A7038

A7039

A7044

A7045

A7046

A7049

A9270

E0561

E0562

E1399

S8186

Diagnosis Codes

Covered sleep apnea Diagnosis Codes for procedure code E0601

G47.31

G47.32

G47.33

G47.34

G47.35

G47.36

G47.37

Non-Covered Diagnosis Code for procedure code E0471

G47.33

Professional Statements and Societal Positions Guidelines

According to the American Academy of Sleep Medicine (AASM) obstructive sleep apnea (OSA) in adults is defined as either:

More than fifteen (15) apneas, hypopneas, or respiratory effort related arousals (RERAs) per hour of sleep (i.e., an apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) greater than fifteen (15) events/hr.) in an asymptomatic individual; or
More than five (5) apneas, hypopneas, or RERAs per hour of sleep (i.e., an AHI or RDI greater than five (5) events per hour) in an individual with symptoms (e.g., sleepiness, fatigue, and inattention), or signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses). More than 75 percent of the apneas or hypopneas must have an obstructive pattern.

The AASM classifies mild, moderate and severe OSA as:

Mild OSA: AHI of 5-15
- Involuntary sleepiness during activities that require little attention, such as watching TV or reading.
Moderate OSA: AHI of 15-30
- Involuntary sleepiness during activities that require some attention, such as meetings or presentations.
Severe OSA: AHI of greater than 30
- Involuntary sleepiness during activities that require more active attention, such as talking or driving.

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Annual Review-no changes

Internal Medical Policy Committee 11-19-2020

Added Professional Statement and statement regarding cleaning devices.

Internal Medical Policy Committee 9-21-2021 Coding update- Effective October 01, 2021

Added new procedure code K1027.

Internal Medical Policy Committee 11-23-2021

Revised the way the not medically necessary statements were written;
Added Daytime electrical stimulation (eXciteOSA) of the tongue.

Internal Medical Policy Committee 3-23-2022 Coding update - E ffective April 01, 2022

Added new procedure codes K1028; & K1029

Internal Medical Policy Committee 3-23-2023 Coding update - Effective April 01, 2023

Added new procedure code A7049.

Internal Medical Policy Committee 5-23-2023 Revision with Coding update - Effective July 03, 2023

Added new statement for new section Sleep Positioning Trainer; and
Added procedure code K1001; and
Added procedure codes A7031; and A7032

Internal Medical Policy Committee 7-26-2023 Revision - Effective September 04, 2023

Updated wording throughout policy

Internal Medical Policy Committee 11-15-2023 Coding - Effective October 01, 2023

Added procedure codes E0490; and E0491.

Internal Medical Policy Committee 1-16-2024 Coding updated - Effective January 01, 2024

Removed procedure codes K1001; K1028; and K1029; and
Added procedure codes D9954; D9955; E0492; E0493 and E0530.

Internal Medical Policy Committee 5-14-2024-Revision- Effective July 01, 2024

Removal of statement regarding PAP device rental period; and
Added Policy Application.

Internal Medical Policy Committee 7-16-2024 Revision - Effective September 02, 2024

Added statement 'Intra-oral devices do not meet the above criteria if there is a signed affidavit refusing CPAP treatment and therefore considered not medically necessary'.

Internal Medical Policy Committee 3-11-2025 Revision - Effective May 05, 2025

Updated Policy Application; and
Removed statement: 'However, if the member is found to be using the PAP device as directed and is achieving the desired results, the DME supplier must contact the individual's physician near the end of the rental period and ask the doctor to prescribe the purchase of the device. Non-compliance, with the prescribed PAP therapy will render the PAP device as a non-covered service.'

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Devices Used for the Treatment of Sleep Apnea in Adults

Description

Policy Application

Criteria

Auto-titrating Positive Airway Pressure (APAP) or Continuous Positive Airway Pressure (CPAP)

Policy Application

Procedure Code

Bi-level Positive Airway Pressure(BiPAP) without back-up rate

Policy Application

Procedure Code

BiPAP with back-up rate

Policy Application

Procedure Code

Central Sleep Apnea

Intra-Oral Appliances

Procedure Codes

Policy Application

Procedure Code

Procedure Codes

Policy Application

Procedure Codes

Policy Application

Policy Application

Procedure Codes

Policy Application

Procedure Code

Accessories

Policy Application

Liners

Policy Application

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Auto-titrating Positive Airway Pressure (APAP) or Continuous Positive Airway Pressure (CPAP)

Policy Application

Procedure Code

Bi-level Positive Airway Pressure(BiPAP) without back-up rate

Policy Application

Procedure Code

BiPAP with back-up rate

Policy Application

Procedure Code

Central Sleep Apnea

Intra-Oral Appliances

Procedure Codes

Policy Application

Procedure Code

Procedure Codes

Policy Application

Procedure Codes

Policy Application

Policy Application

Procedure Codes

Policy Application

Procedure Code

Accessories

Policy Application

Liners

Policy Application

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer