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.
Obstructive Sleep Apnea
Auto-titrating Positive Airway Pressure (APAP) or Continuous Positive Airway Pressure (CPAP)
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 or CPAP devices that do not meet the above criteria are considered not medically necessary.
BiPAP without back-up rate may be considered medically necessary for the treatment ofOSA in adults and covered as durable medical equipment when the following criteria are met:
BiPAP without back-up rate services that do not meet the above criteria is considered not medically necessary.
A BiPAP device with back-up rate is considered not medically necessary with the primary diagnosis of OSA, in adults.
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:
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:
If the above coverage criteria are not met, for devices used for the treatment of OSA, the device is considered not medically necessary. There are many different types of appliances that basically fit into one of two 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.
Nasal EPAP devices (e.g., Provent™, Theravent™) are considered experimental/investigational, and therefore, non-covered. The safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.
OPT devices (e.g., Winx® Sleep Therapy System) are considered experimental/investigational and, therefore, non-covered. The safety and/or effectiveness of this service cannot be established by review of the available published peer-reviewed literature.
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:
Throughout the PAP device rental period, the DME supplier must check that the member is compliant with use of the device. If the device isn’t being used as prescribed, the DME supplier should contact the individual’s physician and discuss removal of the device. If the physician agrees that removal of the machine is warranted, the supplier must remove the machine and discontinue billing for the rental. 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.
Compliance monitoring equipment for CPAPs, APAPs, or BiPAPs (e.g., smart card, compliance chip, tele monitoring, andcomputer 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 thirty (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.
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.
Accessories used with a positive airway pressure (PAP) device are covered when thecriteria for the device are met. If thecriteria are not met, the accessories will be denied as not medically necessary.
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.
|Accessory||Usual Maximum Replacement|
|A4604**||1 per 3 months|
|A7027**||1 per 3 months|
|A7028**||2 per 1 month|
|A7029**||2 per 1 month|
|A7030**||1 per 3 months|
|A7031**||1 per 1 month|
|A7032**||2 per 1 month|
|A7033**||2 per 1 month|
|A7034**||1 per 3 months|
|A7035*||1 per 6 months|
|A7036*||1 per 6 months|
|A7037**||1 per 3 months|
|A7038**||2 per 1 month|
|A7039*||1 per 6 months|
|A7044*||1 per 3 months|
|A7045*||1 per 3 months|
|A7046*||1 per 6 months|
* Allows for a 10 day delivery before run-out
**Allowing for a 3 month supply
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.
Covered sleep apnea Diagnosis Codes for Procedure Code E0601
Non-Covered Diagnosis Codes for Procedure Code E0471
Internal Medical Policy Committee 3-16-2020 Annual Review-no changes
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.