Here at Jay's Medical Equipment, we have a Respiratory Therapist on staff who is always happy to assist you. Our therapist would be more than happy to go over the guidelines for PAP devices with you. Please give us a call today!
Medicare Requirements
The following requirements are set forth by Medicare. Other requirements and/or guidelines may be necessary to follow. Please call our store or your physician for further details.
Definitions
Apnea
- Definition: Cessation of airflow for at least 10 seconds.
Hypopnea
- Definition: An abnormal respiratory event lasting at least 10 seconds associated with:
- At least a 30% reduction in thoracoabdominal movement or airflow compared to baseline.
- At least a 4% decrease in oxygen saturation.
Apnea-Hypopnea Index (AHI)
- Definition: The average number of episodes of apnea and hypopnea per hour of sleep without the use of a positive airway pressure device.
- Note: Respiratory effort-related arousals (RERAs) are not included in this calculation. Sleep time can only be measured in a Type I or Type II sleep study.
Respiratory Disturbance Index (RDI)
- Definition: The average number of apneas plus hypopneas per hour of recording without the use of a positive airway pressure device.
- Note: RERAs are not included in this calculation. The RDI is reported in Type III, Type IV, and other home sleep studies.
Calculation Requirements
If the AHI or RDI is calculated based on less than 2 hours of sleep or recording time, the total number of recorded events used to calculate these indices must meet specific event thresholds.
Initial Coverage Criteria
PAP Devices
In this policy, the term PAP (positive airway pressure) device refers to both a single-level continuous positive airway pressure device (E0601) and a bi-level respiratory assist device without backup rate (E0470) when used in the treatment of obstructive sleep apnea (OSA).
Coverage Criteria for E0601
A device is covered for the treatment of OSA if the following criteria are met:
- Clinical Evaluation: The beneficiary has a face-to-face clinical evaluation by the treating practitioner prior to the sleep test.
- Sleep Test Requirements:
- AHI or RDI ≥ 15 events/hour with a minimum of 30 events, or
- AHI or RDI between 5 and 14 events/hour with a minimum of 10 events and documentation of:
- Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or
- Hypertension, ischemic heart disease, or history of stroke.
- Instruction Received: The beneficiary and/or caregiver has received proper instruction from the supplier in the use and care of the equipment.
If these criteria are not met, claims will be denied as not reasonable and necessary.
Additional Coverage for E0470
An E0470 device is covered for those with OSA who meet the above criteria and have tried an E0601 that was found ineffective.
Important Notes
- A bi-level positive airway pressure device with back-up rate (E0471) is not reasonable and necessary for OSA diagnosis.
- If an E0601 has been used for over 3 months and the beneficiary is switched to an E0470, a new initial face-to-face clinical evaluation is required, but a new sleep test is not.
Sleep Tests
Coverage and payment rules for sleep tests may vary. The DME MAC coverage rules take precedence for PAP therapy.
Types of Sleep Tests
- Type I: Facility-based polysomnogram with comprehensive monitoring.
- Type II: Unattended home sleep test monitoring a minimum of seven channels.
- Type III: Unattended home sleep test monitoring a minimum of four channels.
- Type IV: Unattended home sleep test monitoring a minimum of three channels.
Instructions for HST
Beneficiaries undergoing an HST must receive proper instruction on using the portable monitoring device prior to the test.
Interpretation of Sleep Tests
All sleep tests must be interpreted by a qualified practitioner holding current certification in Sleep Medicine.
The above information is believed to be accurate, but not guaranteed.
