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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 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. 
 
An E0601 device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A  C are met: 
 
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. 
 
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. 
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. 
 
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). 
 
 Sleep Tests 
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.  
 
Repeat sleep test in a facility-based setting (Type 1 study). This may be a repeat diagnostic, titration or split-
night study. 
If an E0601 device is tried and found ineffective during the initial facility-based titration or home trial, 
substitution of an E0470 does not change the length of the trial unless there is less than 30 days remaining in 
the trial period. If more than 30 days remain in the trial period, the clinical re-evaluation would still occur 
between the 31st and 91st day following the initiation of an E0601 and objective documentation of adherence 
on the E0470 would need to occur prior to the 91st day following initiation of the E0601. If less than 30 days 
remain in the trial period, the clinical re-evaluation and objective documentation of adherence must occur 
before the 120th day following the initiation of the E0601. 
 
If an E0601 device was used for more than 3 months and the beneficiary was then switched to an E0470, the 
clinical re-evaluation must occur between the 31st and 91st day following the initiation of the E0470. There 
would also need to be documentation of adherence to therapy during the 3 month trial with the E0470. 
 
If there is discontinuation of usage of a PAP device at any time, the supplier is expected to ascertain this and 
stop billing for the equipment and related accessories and supplies. 
 
For a PAP device dispensed prior to November 1, 2008, if the initial Medicare coverage criteria in effect at the 
time were met and the criteria for coverage after the first 3 months that were in effect at the time were met, the 
device will continue to be covered for dates of service on or after November 1, 2008 as long as the beneficiary 
continues to use the device. 
 
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.