Highmark Medical Policy Bulletin
Section: Durable Medical Equipment
Number: E-20
Topic: Continuous Positive Airway Pressure (CPAP) Device
Effective Date: January 1, 2004
Issued Date: January 5, 2004
Date Last Reviewed: 10/2001

General Policy Guidelines

Indications and Limitations of Coverage

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 (AHI) equal to or greater than 5 (also called the Respiratory Disturbance Index or RDI)

  2. Results of CPAP Trial (at optimum CPAP pressure):
    1. Apnea-Hypopnea Index less than 5, or for patients with AHI greater than 20, reduction in AHI is greater than 75%
    2. No oxygen desaturation less than 85%
    3. Abolition of arrhythmia(s)(e.g., 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)

The claim must also certify that the documentation supporting a diagnosis of OSA is available.

The use of CPAP in the treatment of congestive heart failure (CHF) patients with OSA who do not meet the above criteria will be given individual consideration.  Refer all claims for medical review.

NOTE:
CPAP for a diagnosis of CHF alone is considered investigational.

Heated (E0562, S8182) and non-heated humidification (E0561) 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 E0470 and E0471) 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:
Total payments for a rental item may not exceed its allowable purchase price, except for those items identified as life sustaining DME. For information on continuous rental of life sustaining DME, see Medical Policy Bulletin E-38, Continuous Rental of Life Sustaining Durable Medical Equipment (DME).
NOTE:
The BiPap/ST Ventilatory Support System (code E0472) should not be confused with the BiPap Airway Management System (codes E0470 and E0471). The guidelines in this policy are not applicable to code E0472. See Medical Policy Bulletin E-1, Screening List for Durable Medical Equipment (DME), for guidelines on code E0472.

Description

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).


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.

Procedure Codes

A7030A7031A7032A7033A7034A7035
A7036A7037A7038A7039A7044E0470
E0471E0472E0561E0562E0601S8182
S8186     

Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

Comprehensive / Wraparound / PPO / Major Medical Guidelines

Refer to General Policy Guidelines

Any reference in this bulletin to non-billable services by a network provider may not be applicable to Major Medical.

Managed Care (HMO/POS) Guidelines

Refer to General Policy Guidelines

Publications

PRN References

02/2001, Guidelines clarified for specific Durable Medical Equipment
02/2002, CPAP device coverage guidelines change

References

MCIM 60-9, 60-17

View Previous Versions

[Version 007 of E-20]
[Version 006 of E-20]
[Version 005 of E-20]
[Version 004 of E-20]
[Version 003 of E-20]
[Version 002 of E-20]
[Version 001 of E-20]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.