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Coverage criteria policies

Continuous positive airway pressure (CPAP) - Minnesota Health Care Programs

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.

Administrative Process

Prior authorization is not required for CPAP.

Coverage

CPAP is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

  1. 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;
    or

    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.
  2. Providers may dispense a CPAP device for up to 3 months based on the physician’s order that includes a diagnosis of obstructive sleep apnea (OSA).
  3. Providers may dispense a Bi-PAP device without backup rate for up to 3 months based on the physician’s order that includes a diagnosis of OSA and a failed trial of CPAP.
  4. Providers may dispense a Bi-PAP device with backup rate for recipients with OSA and coexisting breathing disorders.
  5. During the third month of CPAP/Bi-PAP rental, the supplier must verify that the recipient is complying with the ordered treatment. If the recipient is compliant, rental for up to seven (7) additional months is covered.
  6. 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).
  7. Initial CPAP supplies include mask and/or pillow puff, circuit tubing, and headgear.
  8. Before dispensing replacement masks or other accessories, providers must verify with the recipient that the CPAP/Bi-PAP device is still in use, and that replacement of the accessory is necessary because the existing accessory is damaged or otherwise worn out.
  9. A replacement mask or pillow puff 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.
  10. Replacement of filters, whisper swivel, and gaskets to keep unit functional are covered.
  11. 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:
    1. The member’s CPAP is non-functional due to normal wear & tear; AND
    2. The member’s CPAP is no longer covered under manufacturer’s warranty; AND
    3. The member’s CPAP has been determined by the DME vendor to require repairs which are not cost effective.
  12. One type of CPAP will be covered per month.
  13. Warranty is usually one year, and average life of the product is about five years.

Indications that are not covered

  1. Battery operated (portable) CPAP devices
  2. Household humidifier
  3. Vaporizer
  4. Carrying case is a non-covered convenience item and is not medically necessary

Definitions

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.

Codes

Description

E0470

Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0471

Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)

E0472

Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device)

E0601

Continuous airway pressure (CPAP) device

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

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.

Vendor

For in-network benefits to apply, items must be received from a contracted vendor or provider.

Portions of the contents of these coverage criteria relating to Minnesota Public Programs medical coverage criteria are taken directly from the Minnesota Health Care Programs Provider Manual (Revised 2-7-12) at:

http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION
&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_149952#

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Policy activity

  • 06/21/2010 - Date of origin
  • 04/01/2017 - Effective date
Review date
  • 03/2017

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