UM Guidelines
Continuous Positive Airway Pressure (CPAP) Device

Ambulatory Care (AC)

BCBST last reviewed June 10, 2021*

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 [30] day period anytime during the first three [3] 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] *
   

References

  1. 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/

 

 

 

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