CPAP DEVICES & ACCESSORIES
A CPAP DEVICE (E0601) IS COVERED FOR THE TREATMENT OF OBSTRUCTIVE SLEEP APNEA IF CRITERIA A - C ARE MET.
A. The beneficiary has a face-to-face clinical evaluation by the treating physician prior to the sleep test to assess the beneficiary for obstructive sleep apnea.
B. The beneficiary has undergone a sleep study
C. The beneficiary and/or caregiver has received instruction from the supplier of the device in the proper use and care of the equipment.
IF THE CRITERIA ABOVE IS NOT MET, MEDICARE WILL DENY THE CLAIM AS NOT REASONABLE OR NECESSARY.
A BiPAP (E0470) DEVICE IS COVERED FOR THOSE BENEFICIARIES WITH OSA WHO MEET CRITERIA A - C ABOVE, IN ADDITION TO CRITERION D:
D. A CPAP (E0601) device has been tried and proven ineffective based on therapeutic trial conducted in either a facility or in a home setting.
IF THE CRITERIA A - D ABOVE IS NOT MET, MEDICARE WILL DENY THE CLAIM AS NOT REASONABLE OR NECESSARY.
If a CPAP (E0601) device is tried and found ineffective during the initial facility-based titration or home trial, substitution of a BiPAP (E0470) does not require a new initial face-to-face clinical evaluation or a new sleep test.
If a CPAP (E0601) device has been used for more than 3 months and the beneficiary is switched to a BiPAP (E0470), a new initial face-to-face clinical evaluation is required, but a new sleep test is not required. A new 3 month trial would begin for use of the BiPAP (E0470) device.
Accessories used with a 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 reasonable and necessary.