Continuous positive airway pressure (CPAP) is a non-invasive technique for providing low levels of air pressure from a flow generator through a nasal mask. The purpose of CPAP is to prevent the collapse of the oropharyngeal walls and the obstruction of airflow during sleep, which occurs in obstructive sleep apnea (OSA).

Used in the treatment of OSA, CPAP is covered as durable medical equipment when ALL of the following criteria are met:

1. Sleep Study Results:
   
   1. Apnea-Hypopnea Index equal to or greater than 15 (also called the Respiratory Disturbance Index or RDI) or
   2. 2 of the following 4 are met:
   
   

   1. Apnea-Hypopnea Index greater than 10-14
   2. Greater than 20 episodes of oxygen desaturation less than 85% or any one episode of oxygen desaturation less than 70%
   3. Type II second degree heart block or Pause greater than 3 seconds or ventricular tachycardia at a rate greater than 140/minute lasting greater than 15 complexes
   4. Excessive daytime sleepiness documented by either Epworth greater than 10 or MSLT (Multiple Sleep Latency Test) less than 6.

2. Results of CPAP Trial (at optimum CPAP pressure):
   
   1. Apnea-Hypopnea Index less than 5
   2. No oxygen desaturation less than 85%
   3. Abolition of arrhythmia(s) described in 1.b.3
   4. In patients with Apnea-Hypopnea Index equal to or greater than 15, reduction greater than 75%
   
   

Heated (K0531) and non-heated humidification (K0268) is eligible for use with CPAP when prescribed by the treating physician to meet the needs of the individual patient.

The BiPap Airway Management System (codes K0532 and K0533) differs from the CPAP device in that it has the ability to alter pressures on expiration, which a nasal CPAP cannot do. See Medical Policy Bulletin E-34, Respiratory Assist Devices, for information on BiPAP.

Coverage for durable medical equipment is determined according to individual or group customer benefits.

NOTE:

The BiPap/ST Ventilatory Support System (code K0534) should not be confused with the BiPap Airway Management System (codes K0532 and K0533). The guidelines in this policy are not applicable to code K0534. See Medical Policy Bulletin E-1, Screening List for Durable Medical Equipment (DME), for guidelines on code K0534.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Refer to Capped Rental Agreement, as appropriate.

PRN References

02/2001, Guidelines clarified for specific Durable Medical Equipment