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 (attended or unattended):
   
   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.

When all the above criteria are met, payment will be made for the rental of a CPAP device for the first three months from the original start date of therapy. After members have been using a CPAP device for three months, are found to be maintaining compliance with its use, and are experiencing success in treatment, payment will be made for the purchase of the device (after the expenses incurred for the first three month’s rental have been applied to the purchase price).

Throughout the CPAP device rental period, the DME supplier should check that the member is compliant with use of the device. If the device isn’t being used as prescribed, the DME supplier should contact the patient’s physician and discuss removal of the device. If the physician agrees that removal of the machine is warranted, the supplier should remove the machine and discontinue billing for the rental. However, if the member is found to be using the CPAP machine as directed and is achieving the desired results, the DME supplier should contact the patient’s physician near the end of the rental period and ask the doctor to prescribe the purchase of the device.

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.

NOTE:

See Medical Policy Bulletin Z-8 for information on attended or unattended sleep studies.

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.

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.

NOTE:

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.

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