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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 hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds associated 
with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at 
least a 4% decrease in oxygen saturation. 
 
The apnea-hypopnea index (AHI) is defined as the average number of episodes of apnea and hypopnea per 
hour of sleep without the use of a positive airway pressure device. For purposes of this policy, respiratory effort 
related arousals (RERAs) are not included in the calculation of the AHI. Sleep time can only be measured in a 
Type I (facility based polysomnogram) or Type II sleep study (see descriptions below). 
 
The respiratory disturbance index (RDI) is defined as the average number of apneas plus hypopneas per hour of 
recording without the use of a positive airway pressure device. For purposes of this policy, respiratory effort 
related arousals (RERAs) are not included in the calculation of the RDI. The RDI is reported in Type III, Type 
IV, and other home sleep studies. 
 
If the AHI or RDI is calculated based on less than 2 hours of sleep or recording time, the total number of 
recorded events used to calculate the AHI or RDI (respectively) must be at least the number of events that 
would have been required in a 2 hour period (i.e., must reach =30 events without symptoms or =10 events with 
symptoms). 
 
INITIAL COVERAGE: 
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. 
 
    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. 
 
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.