Description:

Continuous Positive Airway Pressure (CPAP) devices deliver pressure to maintain an open airway during sleep. This therapy is used for the treatment of Obstructive Sleep Apnea.
Medicare's Medical Coverage Criteria:

A single level continuous positive airway pressure (CPAP) device is covered if the patient has a diagnosis of obstructive sleep apnea (OSA) documented by an attended, facility-based polysomnogram and meets either of the following criteria (1 or 2):

  1. The AHI is =15 events per hour, or
  2. The AHI is from 5 to 14 events per hour with documented symptoms of:
    - Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia, or
    - Hypertension, ischemic heart disease, or history of stroke.

The AHI must be calculated based on a minimum of 2 hours of recorded sleep and must be calculated using actual recorded hours of sleep (i.e. the AHI may not be an extrapolated or projected calculation).

If a continuous positive airway pressure device is provided and the criteria above has not been met, it will be denied as not medically necessary.

For the purpose of this policy, polysomnographic studies must be performed in a facility based sleep study laboratory, and not in the home or in a mobile facility. These labs must be qualified providers of Medicare services and comply with all applicable state regulatory requirements.

Continuous Positive Airway Pressure / CPAP

CPAP

CLOSE WINDOW

For the purpose of this policy, polysomnographic studies must not be performed by a DME supplier or any entity with a financial relationship to a DME supplier. A DME supplier or supplier with significant financial interest in such facilities would not be considered a qualified provider or supplier of these tests for purposes of this policy's coverage and payment guidelines. This prohibition does not extend to the results of studies conducted by hospitals certified to do such tests.

Continued Coverage beyond the First Three Months of Therapy

Continued coverage of a CPAP device beyond the first three months of therapy requires that, no sooner than the 61 st day after initiating therapy, the supplier ascertain from either the beneficiary or the treating physician that the beneficiary is continuing to use the CPAP device.

If the above criterion is not met, continued coverage of a CPAP device and related accessories will be denied as not medically necessary.