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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 say that an E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A  
C are met: 
 
        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): 
 
            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, 
 
            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: 
 
                Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or, 
                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: 
 
        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. A bi-level positive airway pressure device with back-up rate (E0471) is not reasonable and 
necessary if the primary diagnosis is OSA. If an E0471 is billed with a diagnosis of OSA, it will be denied as 
not reasonable and necessary. If an E0601 device is tried and found ineffective during the initial facility-based 
titration or home trial, substitution of an E0470 does not require a new initial in-person clinical evaluation or a 
new sleep test. If an E0601 device has been used for more than 3 months and the beneficiary is switched to an 
E0470, a new initial in-person clinical evaluation is required, but a new sleep test is not required. A new 3-
month trial would begin for use of the E0470. 
 
Coverage of a PAP device for the treatment of OSA is limited to claims where the diagnosis of OSA is based 
upon all of the following: 
 
    A sleep test (Type I, II, III, IV, Other) that meets the Medicare requirements for a valid sleep test as outlined 
in NCD 240.4.1 and the applicable A/B MAC LCD and Billing and Coding article; and, 
 
    A sleep test that is approved by the Food and Drug Administration (FDA) as a diagnostic device; and, 
 
    The sleep test results meet the coverage criteria in effect for the date of service of the claim for the PAP 
device; and, 
 
    The sleep test is ordered by the beneficiarys treating practitioner; and, 
    The sleep test is conducted by an entity that qualifies as a Medicare provider of sleep tests and is in 
compliance with all applicable state regulatory requirements.  
 
You can find this rule 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.