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LCD - CPAP / BiPAP For Diagnosis of Obstructive Sleep Apnea (OSA)

Coverage Summary

CPAP is ONLY covered with an OSA (327.23) diagnosis and the following criteria is documented:
  1. Clinical evaluation documenting signs and symptoms of OSA PRIOR to a sleep test.
  2. Sleep test resulting in the AHI or RDI greater than or equal to 15 events per hour with a minimum of 30 events OR; The AHI or RDI is greater than or equal to 5 events and less than or equal to 14 events per hour with a minimum of 10 events AND documentation of: excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; hypertension, ischemic heart disease, or history of stroke
  3. Interpretation of Sleep Test by a qualified physician
  4. Oxygen with CPAP is covered if the patient continues to desat after the obstructive apneas have been resolved during the titration study.
  5. Oxygen is NOT covered with a diagnosis of OSA.

Order Requirements

  1. Patient's Name
  2. Detailed description of item(s) being ordered such as description of device, heated humidifier, type of mask (nasal, full face, oral), headgear, filters and/or tubing.
  3. Pressure settings       
  4. Qty to be dispensed
  5. Frequency of use or duration
  6. Ordering Physician’s NPI
  7. Ordering physician’s legible signature (personally written or electronically signed by the physician, stamps are not accepted by insurance).
  8. Ordering physician’s legible signature date (personally written or electronically signed by the physician, stamps are not accepted by insurance).
  9. Start date of the order – if different than the Physician's signature date.

Note: Detailed written orders are required prior to delivery. Summary orders such as "Cpap and Supplies" is not accepted by insurance. Each ordered item must be specifically defined with quantity ordered.

Coverage Detail

The term PAP (positive airway pressure) device will refer to both a single-level continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up rate (E0470) when it is used in the treatment of obstructive sleep apnea.

I. An CPAP device (E0601) is covered for the treatment of obstructive sleep apnea (OSA) if criteria A – C are met:

A.The patient has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the beneficiary for obstructive sleep apnea.

B. The patient has a sleep test (as defined below) that meets either of the following criteria (1 or 2):

    1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,
    2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
      1. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,
      2. Hypertension, ischemic heart disease, or history of stroke.
  • The Sleep Test must be interpreted by a physician who holds either:
    1. Certification PRIOR to 2007: Current certification in Sleep Medicine by the American Board of Sleep (American Board of Sleep Medicine (ABSM)) or;
    2. Certification AFTER 2007: Current subspecialty certification in Sleep Medicine by a member board of the American Board of Medical Specialties (American Board of Medical Specialties (ABMS)) or;
    3. Completed residency of fellowship training by an American Board of Sleep Medicine member board (American Board of Sleep Medicine (ABSM)) and has completed all the requirements for subspecialty certification in sleep medicine except the examination itself and only until the time of reporting the first examination for which the physician is eligible, or;
    4. Active staff membership of a sleep center or laboratory accredited by the American Academy of Sleep Medicine (American Academy of Sleep)

C. The patient and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.

II. A Bi-level device (E0470) is covered for those patients with OSA who meet criteria A-C above, in addition to criterion D:

D. A CPAP (E0601) has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting.