Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve additional 3 month trial of CPAP. We decided that the Plan does 
not have to pre-approve CPAP with humidifier after the three month trial of CPAP if requirements are not met 
at that time.  
 
You asked the Plan to pre-approve additional 3 month trial of CPAP. You say that you would like the plan to 
reconsider their denial. The Plan says that the requested services are not medically necessary. 
 
We decided that the Plan has to pre-approve additional 3 month trial of CPAP.  
 
The Plan follows Medicare rules. Medicare rules say that continued coverage of a PAP device (E0470 or 
E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 
91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document 
that the beneficiary is benefiting from PAP therapy. For PAP devices with initial dates of service on or after 
November 1, 2008, documentation of clinical benefit is demonstrated by: 
1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
sleep apnea are improved; and, 
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. 
 
Adherence to therapy is defined as use of PAP greater than or equal to 4 hours per night on 70% of nights 
during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve additional 3 month trial of CPAP. Our 
reviewer says that the documentation does not support that criteria for CPAP are met. Our physician reviewer 
found you 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of additional 3 month trial of CPAP have been met. Therefore, we decided that the 
Plan has to pre-approve additional 3 month trial of CPAP.  
 
We also decided that the Plan does not have to pre-approve continued CPAP with humidifier after the 
three month trial of CPAP if requirements are not met at that time. 
 
The Plan follows Medicare rules. Medicare rules say that continued coverage of a PAP device (E0470 or 
E0601) beyond the first three months of therapy requires that, no sooner than the 31st day but no later than the 
91st day after initiating therapy, the treating practitioner must conduct a clinical re-evaluation and document 
that the beneficiary is benefiting from PAP therapy. For PAP devices with initial dates of service on or after 
November 1, 2008, documentation of clinical benefit is demonstrated by: 
1. In-person clinical re-evaluation by the treating practitioner with documentation that symptoms of obstructive 
sleep apnea are improved; and, 
2. Objective evidence of adherence to use of the PAP device, reviewed by the treating practitioner. 
 
Adherence to therapy is defined as use of PAP greater than or equal to 4 hours per night on 70% of nights 
during a consecutive thirty (30) day period anytime during the first three (3) months of initial usage. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve CPAP with humidifier. Our reviewer 
says that the documentation does not support that criteria for CPAP are met. Our physician reviewer found you 
have mild obstructive sleep apnea. You are unable to meet minimum usage requirements because of problems 
tolerating the mask. There have been two clinical visits to address this, the most recent in July 2020, with plans 
to re-fit the mask. It has been less than a year since your previous polysomnography (PSG) and positive airway 
pressure therapy titration; it seems unlikely that repeating the PSG/titration study will address the issue of mask 
tolerance. It is reasonable and necessary for you to have an additional 3 month trial of CPAP to see if mask 
tolerance, and compliance, can be achieved after re-fitting of the mask. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of CPAP with humidifier have not been met. Therefore, we decided that the Plan 
does not have to pre-approve CPAP with humidifier after the three month trial of CPAP if requirements are not 
met at that time. 
 
 
 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.