: Key Coverage Criteria Required for All CPAP Claims
A single-level CPAP device (E0601) is covered for the treatment of OSA if criteria A-C are met:
A. The patient has face-to-face clinical evaluation by treating physician prior to the sleep test to assess the patient for OSA.
NOTE: Physicians shall document the face-to-face evaluation and re-evaluation in a detailed narrative note in their charts. For the initial evaluation, the report would commonly document pertinent information (ie, history and physical exam), but may include other details.
B. The patient has a Medicare-covered sleep test that meets either of the following criteria:
1. The apnea–hypopnea index (AHI) or respiratory disturbance index (RDI)*
is ≥ 15 events per hour with minimum of 30 events; or
2. The AHI or RDI is ≥ 5 and ≤ 14 events per hour with minimum of 10 events and documentation of:
a. Excessive daytime sleepiness, impaired cognition,
mood disorders or insomnia; or
b. Hypertension, ischemic heart disease or history of stroke
C. The patient and/or their caregiver has received instruction from the supplier of the CPAP device and accessories in the proper use and care of the equipment.
The RDI is defined as the average number of apneas plus hypopneas per hour of recording without the use of a positive airway pressure (PAP) device.