Used in the treatment of OSA, CPAP is covered as durable medical equipment when ALL of the following criteria are met:

1. Sleep Study Results:
   
   1. Apnea-Hypopnea Index (AHI) equal to or greater than 5 (also called the Respiratory Disturbance Index or RDI)
      
   
   
2. Results of CPAP Trial (at optimum CPAP pressure):
   
   1. Apnea-Hypopnea Index less than 5, or for patients with AHI greater than 20, reduction in AHI is greater than 75%
   2. No oxygen desaturation less than 85%
   3. Abolition of arrhythmia(s)(e.g., Type II second degree heart block or pause greater than 3 seconds or ventricular tachycardia at a rate greater than 140/minute lasting greater than 15 complexes)

The claim must also certify that the documentation supporting a diagnosis of OSA is available.

The use of CPAP in the treatment of congestive heart failure (CHF) patients with OSA who do not meet the above criteria will be given individual consideration.  Refer all claims for medical review.

NOTE:

CPAP for a diagnosis of CHF alone is considered investigational. A participating, preferred, or network provider can bill the member for this denied service. 

Heated (E0562) and non-heated humidification (E0561) is eligible for use with CPAP when prescribed by the treating physician to meet the needs of the individual patient.

The BiPap Airway Management System (codes E0470 and E0471) differs from the CPAP device in that it has the ability to alter pressures on expiration, which a nasal CPAP cannot do. See Medical Policy Bulletin E-34, Respiratory Assist Devices, for information on BiPAP.

Coverage for durable medical equipment is determined according to individual or group customer benefits.

NOTE:

Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).

NOTE:

The BiPap/ST Ventilatory Support System (code E0472) should not be confused with the BiPap Airway Management System (codes E0470 and E0471). The guidelines in this policy are not applicable to code E0472. See Medical Policy Bulletin E-1, Screening List for Durable Medical Equipment (DME), for guidelines on code E0472.

Description

Continuous positive airway pressure (CPAP) is a non-invasive technique for providing low levels of air pressure from a flow generator through a nasal mask. The purpose of CPAP is to prevent the collapse of the oropharyngeal walls and the obstruction of airflow during sleep, which occurs in obstructive sleep apnea (OSA).

Acclimation efforts are expected for a minimum of two months, and must be supported by proper documentation and compliance chip information before CPAP will be considered failed.  Adequate adherence to CPAP is defined as > 4.5 hours of CPAP use per night on a routine basis.  Maximal improvement in neurocognitive symptoms can require as long as 2 months of CPAP treatment.  A newly diagnosed member with OSA must be given a CPAP machine with a compliance chip.  New purchases or replacements of CPAP machines for members with an existing diagnosis of OSA do not need a compliance chip. 

PRN References

02/2001, Guidelines clarified for specific Durable Medical Equipment
02/2002, CPAP device coverage guidelines change

MCIM 60-9, 60-17