|Continuous Positive Airway Pressure (CPAP) Device|
Ambulatory Care (AC)
|BCBST last reviewed June 10, 2021*|
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Changed Clinical Indications include the following:
- Continuous positive airway pressure (CPAP) may be indicated for 1 or more of the following:
- [Initial Therapy (rental) request for 1 or more of the following conditions:] *
- Central sleep apnea syndrome...
- Obesity hypoventilation syndrome, and CPAP ...
- Obstructive sleep apnea, and CPAP ...
- [Continued coverage (purchase) request for CPAP beyond the first three months of therapy when ALL of the following are met:
- In person clinical re-evaluation by the treating practitioner no sooner than the 31st day but no later than the 91st day
- Documentation that symptoms of obstructive sleep apnea are improved
- Objective evidence of adherence (adherence defined as use of CPAP 4 hours or more per night on 70% of nights during a consecutive thirty  day period anytime during the first three  months of initial usage)
- Replacement of CPAP device with 1 or more of the following:
- Within the 5 year reasonable useful lifetime (RUL) with documentation of loss, theft, or irreparable damage due to a specific incident
- After the 5 year reasonable useful lifetime (RUL) with ALL of the following:
- Documentation of an in person evaluation by treating practitioner
- Documentation that the patient continues to use and benefit from CPAP] *
- CGS Administrators, LLC. (2020). Local Coverage Determination (LCD): Positive airway pressure (PAP) devices for the treatment of obstructive sleep apnea (L33718). Retrieved March 22, 2021 from https://www.cms.gov/