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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 apnea is defined as the cessation of airflow for at least 10 seconds. 
 
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). Projections of AHI or RDI based upon shorter testing times and/or fewer events are not acceptable 
for use in determining eligibility for payment. 
 
For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a 
Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS 
item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the 
claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the 
bottom of this policy under the Related Local Coverage Documents section. 
 
For DMEPOS base items that require a WOPD, and also require separately billed associated options, 
accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may 
list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the 
items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies 
without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be 
denied as not reasonable and necessary. 
 
An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, 
LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be 
denied as not reasonable and necessary/incorrectly coded. 
 
Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD 
documentation in their files. Proof of delivery documentation must be made available to the Medicare 
contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be 
denied as not reasonable and necessary. You can find this rule in the Local Coverage Determination (LCD) 
Oral Appliances for Obstructive Sleep Apnea L33611. 
 
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.