Highmark Medical Policy Bulletin |
Section: | Durable Medical Equipment |
Number: | E-20 |
Topic: | Continuous Positive Airway Pressure (CPAP) Device |
Effective Date: | December 14, 2009 |
Issued Date: | May 9, 2011 |
Date Last Reviewed: |
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:
The claim must also certify that the documentation supporting a diagnosis of OSA is available. When all the above criteria are met, payment will be made for the rental of a CPAP device for the first three months from the original start date of therapy. After members have been using a CPAP device for three months, are found to be maintaining compliance with its use, and are experiencing success in treatment, payment will be made for the purchase of the device (after the expenses incurred for the first three month’s rental have been applied to the purchase price). Throughout the CPAP device rental period, the DME supplier should check that the member is compliant with use of the device. If the device isn’t being used as prescribed, the DME supplier should contact the patient’s physician and discuss removal of the device. If the physician agrees that removal of the machine is warranted, the supplier should remove the machine and discontinue billing for the rental. However, if the member is found to be using the CPAP machine as directed and is achieving the desired results, the DME supplier should contact the patient’s physician near the end of the rental period and ask the doctor to prescribe the purchase of the device. 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.
Accessories Accessories used with a continuous positive airway pressure (CPAP) device are covered when the coverage criteria for the device are met. If the coverage criteria are not met, the accessories will be denied as not medically necessary. The following represents the usual maximum amount of accessories expected to be medically necessary:
Quantities of supplies greater than those described in the policy as the usual maximum amounts will be denied as not medically necessary. Heated (E0562) 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.
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). |
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A4604 | A7027 | A7028 | A7029 | A7030 | A7031 |
A7032 | A7033 | A7034 | A7035 | A7036 | A7037 |
A7038 | A7039 | A7044 | A7046 | E0470 | E0471 |
E0472 | E0561 | E0562 | E0601 | S8186 |
Traditional (UCR/Fee Schedule) Guidelines
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program. |
Comprehensive / Wraparound / PPO / Major Medical 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
PRN References 02/2001, Guidelines clarified for specific Durable Medical Equipment |
DME MAC Jurisdiction A, L11528 CMS Pub. 100-03, Medicare National Coverage Determinations Manual, Chapter 1, Section 240.4 |