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Section: Durable Medical Equipment
Number: E-20
Topic: Continuous Positive Airway Pressure (CPAP) Device
Effective Date: August 31, 2009
Issued Date: September 3, 2009
Date Last Reviewed: 09/2009

General Policy Guidelines

Indications and Limitations of Coverage

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) (i.e. titration study):
    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.

Accessories

Accessories used with a continuous positive airway pressure (CPAP) device are covered when the coverage criteria for the device are met. If the coverage criteria are not met, the accessories will be denied as not medically necessary.

The following represents the usual maximum amount of accessories expected to be medically necessary:

A4604
1 per 3 months
Tubing with integrated heating element for use with positive airway pressure device
A7027
1 per 3 months
Combination oral/nasal mask, used with continuous positive airway pressure device, each
A7028
2 per 1 month
Oral cushion for combination oral/nasal mask, replacement only, each
A7029
2 per 1 month
Nasal pillows for combination oral/nasal mask, replacement only, pair
A7030
1 per 3 months
Full face mask used with positive airway pressure device, each

A7031
1 per 1 month

Face mask interface, replacement for full face mask, each
A7032
2 per 1 month
Cushion for use on nasal mask interface, replacement only, each
A7033
2 per 1 month
Pillow for use on nasal cannula type interface, replacement only, pair
A7034
1 per 3 months
Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap
A7035
1 per 6 months
Headgear used with positive airway pressure device
A7036
1 per 6 months
Chinstrap used with positive airway pressure device
A7037
1 per 3 months
Tubing used with positive airway pressure device
A7038
2 per 1 month
Filter, disposable, used with positive airway pressure device
A7039
1 per 6 months
Filter, non disposable, used with positive airway pressure device
A7046
1 per 6 months
Water chamber for humidifier, used with positive airway pressure device, replacement, each

Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not medically necessary.

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.

Services that do not meet the medical necessity criteria on this policy will be considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

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 or other compliance monitoring mechanisms 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.

Procedure Codes

A4604A7027A7028A7029A7030A7031
A7032A7033A7034A7035A7036A7037
A7038A7039A7044A7046E0470E0471
E0472E0561E0562E0601S8186 

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

DME MAC Jurisdiction A, L11528

CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 240.4

Blue Cross Blue Shield of North Carolina Medical Policy Number OTH8138 (Sleep Apnea and Breathing Related Sleep Disorders in Adults) Origination: 10/2000

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Glossary





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.



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