Appeal type: DME/ Orthotics
Decision: Partially Favorable

 
We decided that the Plan has to pre-approve a CPAP device for 3 months. We decided that the Plan does not 
have to pre-approve a CPAP device beyond 3 additional months.  
 
You asked the Plan to pre-approve a continuous positive airway pressure (CPAP) device (E0601). You say that 
the services are necessary. The Plan says that based on the documentation provided, coverage criteria have not 
been met. 
 
We decided that the Plan has to pre-approve a CPAP device for 3 months.  
 
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.   
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 a CPAP device for 3 months. Our 
reviewer says that the services are medically necessary. Our physician reviewer found continuation of CPAP 
for 3 months is considered reasonable and medically necessary. Device compliance covering the month of 
August showed only 27% of days with use for at least 4 hours/day. This does not meet Medicare criteria of at 
least 70% of days. CPAP compliance issues were addressed at a clinical visit on November 21, 2023. The 
enrollee now has a case manager who will help the enrollee adjust to CPAP and achieve device compliance. An 
additional 3 months of coverage to provide another opportunity to achieve compliance is considered 
reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CPAP device for 3 months have been met. Therefore, we decided that the Plan 
has to pre-approve a CPAP device for 3 months.  
 
We also decided that the Plan does not have to pre-approve a CPAP device beyond 3 additional months. 
 
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.  
 
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 a CPAP device beyond 3 additional 
months. Our reviewer says that the services are not medically necessary. Our physician reviewer found 
continuation of CPAP for 3 months is considered reasonable and medically necessary. Device compliance 
covering the month of August showed only 27% of days with use for at least 4 hours/day. This does not meet 
Medicare criteria of at least 70% of days. CPAP compliance issues were addressed at a clinical visit on 
November 21, 2023. The enrollee now has a case manager who will help the enrollee adjust to CPAP and 
achieve device compliance. An additional 3 months of coverage to provide another opportunity to achieve 
compliance is considered reasonable. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a CPAP device beyond 3 additional months have not been met. Therefore, we 
decided that the Plan does not have to pre-approve a CPAP device beyond 3 additional months. 
 
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.