Policy Statement
Accessories used with PAP devices may be covered when criteria for the device are met. Our health plan utilizes Centers for Medicare & Medicaid Services (CMS) Local Coverage Determinations (LCD) to determine the reasonable and necessary maximum quantities and frequencies for PAP accessory purchases. Our health plan has, at our discretion, increased the CMS maximum quantities and/or frequencies as we deemed appropriate.
When the total units of service for a Healthcare Common Procedure Coding System (HCPCS) code have exceeded the maximum allowed within the specified time frame, our health plan will allow up to that limit and deny the remaining units. Our health plan will allow up to a 10-day grace period.
Example: Two (2) units of HCPCS A7029 are purchased on 04/01/2026. The member may receive up to four (4) additional units of HCPCS A7029 prior to 06/30/2026, for a total of six (6) units of HCPCS A7029 purchased within a 3 month/90-day period.
Billing of PAP accessories must be based on prospective, not retrospective, use. Suppliers must contact the member prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the member. This will be done to ensure that the items remain reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes or modifications to the order. Items delivered without a valid, documented refill request from the member will be denied as not reasonable and necessary.
