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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that in this policy, the term PAP (positive airway pressure) device will refer to both a single-level continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without back-up rate (E0470) when it is used in the treatment of obstructive sleep apnea.
A. The beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test to assess the beneficiary for obstructive sleep apnea.
B. The beneficiary has a sleep test (as defined below) that meets either of the following criteria (1 or 2):
1. The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,
2. The AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
a. Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,
b. Hypertension, ischemic heart disease, or history of stroke.
C. The beneficiary and/or their caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.
If a claim for an E0601 is submitted and all of the criteria above have not been met, it will be denied as not reasonable and necessary.
An E0470 device is covered for those beneficiaries with OSA who meet criteria A-C above, in addition to criterion D:
D. An E0601 has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting.
Ineffective is defined as documented failure to meet therapeutic goals using an E0601 during the titration portion of a facility-based study or during home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings). If E0470 is billed for a beneficiary with OSA and criteria A-D are not met, it will be denied as not reasonable and necessary.
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 four (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.
You can find these rules in the Local Coverage Determination (LCD) Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea, L33718.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.