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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 continuous positive airway pressure (CPAP) therapy when used in adult patients with 
obstructive sleep apnea (OSA) is considered reasonable and necessary under the following situations: 
 
1. The use of CPAP is covered under Medicare when used in adult patients with OSA. Coverage of CPAP 
is initially limited to a 12-week period to identify beneficiaries diagnosed with OSA as subsequently described 
who benefit from CPAP. CPAP is subsequently covered only for those beneficiaries diagnosed with OSA who 
benefit from CPAP during this 12-week period. 
2. The provider of CPAP must conduct education of the beneficiary prior to the use of the CPAP device to 
ensure that the beneficiary has been educated in the proper use of the device. A caregiver, for example a family 
member, may be compensatory, if consistently available in the beneficiary's home and willing and able to 
safely operate the CPAP device. 
3. A positive diagnosis of OSA for the coverage of CPAP must include a clinical evaluation and a 
positive: 
   a. attended polysomnography (PSG) performed in a sleep laboratory; or 
   b. unattended home sleep test (HST) with a Type II home sleep monitoring device; or 
   c. unattended HST with a Type III home sleep monitoring device; or 
   d. unattended HST with a Type IV home sleep monitoring device that measures at least 3 channels. 
4. The sleep test must have been previously ordered by the beneficiarys treating physician and furnished 
under appropriate physician supervision. 
5. An initial 12-week period of CPAP is covered in adult patients with OSA if either of the following 
criterion using the Apnea-Hypopnea Index (AHI) or  respiratory disturbance index (RDI) are met: 
   a. AHI or RDI greater than or equal to 15 events per hour, or 
   b. AHI or RDI greater than or equal to 5 events and less than or equal to 14 events per hour with 
documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or 
documented hypertension, ischemic heart disease, or history of stroke. 
6. The AHI or RDI is calculated on the average number of events of per hour. If the AHI or RDI is 
calculated based on less than 2 hours of continuous recorded sleep, the total number of recorded events to 
calculate the AHI or RDI during sleep testing must be at a minimum the number of events that would have 
been required in a 2-hour period. 7. Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal 
respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or 
airflow as compared to baseline, and with at least a 4% oxygen desaturation. 
8. Coverage with Evidence Development (CED): Medicare provides the following limited coverage for 
CPAP in adult beneficiaries who do not qualify for CPAP coverage based on criteria 1-7 above. 
 
You can find this information in the Centers for Medicare and Medicaid Services (CMS), Internet-Only 
Manual, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Section 240.4. 
 
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.