Mountain State Medical Policy Bulletin |
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 |
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:
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.
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:
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.
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.
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. |
A4604 | A7027 | A7028 | A7029 | A7030 | A7031 |
A7032 | A7033 | A7034 | A7035 | A7036 | A7037 |
A7038 | A7039 | A7044 | A7046 | E0470 | E0471 |
E0472 | E0561 | E0562 | E0601 | S8186 |
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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