These services may or may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.
Prior authorization is not required for CPAP.
CPAP is generally covered subject to the indications listed below and per your plan documents.
- Must be part of treatment plan for an appropriate medical condition. Examples include, but are not limited to, OSA, UARS, or a combination of sleep disorders which include OSA;
Must have a preliminary diagnosis of OSA or UARS and have a sleep study scheduled to confirm diagnosis. Sleep study must confirm diagnosis of moderate - severe OSA or UARS in order for coverage of CPAP to continue.
- Humidity devices, for use with CPAP, are covered for members with dried airways, nose bleeds or nasal polyps. Coverage is available for cool mist units or heated humidity (rent or purchase).
- Initial CPAP supplies that include mask and /or pillowpuff, curcuit/tubing, and headgear.
- A replacement mask or pillowpuff is covered when the item is worn out to due to normal wear and tear or when the initial one is medically not appropriate for the member. Replacement headgear and circuit is also covered.
- Replacement of filters, whisper swivel, and gaskets to keep unit functional.
- A member’s initial CPAP, when provided by the Health Plan, will be rented up to the time the payments have reached the purchase price, at which time the machine becomes owned by the member.
- Replacement CPAP (CPAP E0601 RR) (whether the initial CPAP was received through HealthPartners or another health plan) may be purchased outright if all of the following criteria are met:
- The member’s CPAP is non-functional due to normal wear & tear; AND
- The member’s CPAP is no longer covered under manufacturers warranty; AND
- The member’s CPAP has been determined by the DME vendor to require repairs which are not cost effective.
- One type of CPAP will be covered per month.
- Warranty is usually one year, and average life of the product is about five years.
Indications that are not covered
- Battery operated (portable) CPAP devices
- Household humidifier.
CPAP is a device used for obstructive sleep apnea. CPAP provides low levels of air pressure from a flow generator, through a nose mask and into the nose. This air pressure keeps the airway open and prevents obstructive sleep apnea. Obstructive sleep apnea (OSA) is a result of an obstructed (blocked) airway. The breathing muscles will continue to move the chest but, because of the obstruction, air will not be able to move in or out of the lungs.
Upper airway resistance syndrome (UARS) is a condition in which a narrowed upper airway does not cause identified apneas. Since the upper airway is narrowed, the muscles have to work harder to move air in and out of the lungs. This increased work load leads to day and nighttime sleep disturbances.
If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.
Continuous airway pressure (CPAP) device
CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.
For in-network benefits to apply, item must be received from a contracted vendor or provider.