CORONAVIRUS (COVID-19)

Resources on COVID-19 and how BCBSND is responding to help protect all North Dakotans

Devices Used for the Treatment of Sleep Apnea in Adults

Section: Durable Medical Equipment
Effective Date: April 15, 2019
Revised Date: June 04, 2019
Last Reviewed: March 15, 2019

Description

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

Criteria

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

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

CPAP

  • Patients 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 patient; or
    • Greater than five (5) events per hour of sleep in a symptomatic patient (e.g., sleepiness, fatigue and inattention); or
    • Signs of disturbed sleep (e.g., snoring, restless sleep, and respiratory pauses).

APAP or CPAP devices that do not meet the above criteria are considered not medically necessary.

Procedure Codes

E0601

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

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

  • Patients 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 patient, or
    • Five (5) events per hour of sleep in a symptomatic patient (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:
      • Patients have failed a prior trial of CPAP. If the patient is uncomfortable or intolerant of high pressures on CPAP; the patient may be tried on BiPAP. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the patient may be switched to BiPAP; or
      • For whom BiPAP is found to be more effective in the sleep lab.

BiPAP without back-up rate services that do not meet the above criteria is considered not medically necessary.

Procedure Codes

E0470

BiPAP with back-up rate

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

Procedure Codes

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 patient’s prescribed FIO2.

Intra-Oral Appliances

Intraoral appliances (tongue-retaining devices or mandibular advancing/positioning devices) may be considered medically necessary in adult patients 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 patient or greater than five (5) events per hour of sleep in a symptomatic patient (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.

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 patients with severe OSA, as oral appliances have been shown to be less efficacious in patients with severe OSA than they are in patients with mild-moderate OSA. Therefore, it is particularly important that patients 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

E0485 E0486

Nasal Expiratory Positive Airway Pressure (EPAP)

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.

Procedure Codes

E1399

Oral Pressure Therapy (OPT) 

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.

Procedure Codes

A7002 A7047 E0600

Payment for the rental of a PAP device

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, tele monitoring, computer software) of device usage for three (3) consecutive months; and
  • The patient is experiencing success in treatment.

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 patient’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 patient’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, 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, tele monitoring, 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, tele monitoring, computer software), has been confirmed in the medical record.

Procedure Codes

E0470 E0471 E0601

Accessories

Liners

Liners are not interfaces for use with a PAP mask. Liners are products placed between the patient’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 the criteria for the device are met. If the criteria 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.

Procedure Codes

A4604 A7027 A7028 A7029 A7030 A7033 A7034
A7035 A7036 A7037 A7038 A7039 A7044 A7045
A7046 A9270 E0561 E0562 E1399 S8186

Diagnosis Codes

Covered sleep apnea Diagnosis Codes for Procedure Code E0601

G47.33 G47.31 G47.32 G47.34 G47.35 G47.36 G47.37

Non-Covered Diagnosis Codes for Procedure Code E0471

G47.33

Links