|
32.2.3 Continuous Positive Airway Pressure (CPAP) and Bi-level Positive Airway Pressure (BiPAP) Systems
A CPAP system is used primarily for the treatment of obstructive sleep apnea. Other conditions may be considered based on medical necessity.
CPAP and BiPAP systems require authorization. Providers may submit evidence of medical necessity with the first claim to the CSHCN Services Program claims contractor. The rental of BiPAP machines will only be provided to clients who have documented failure with a CPAP device.
Use procedure code E0601 for the CPAP system.
Use procedure code E0470, E0471, or E0472 for the BiPAP system.
The CPAP system may be prior authorized for rental or purchase based on the physician's predicted length of treatment.
The CPAP system may be approved initially for a 3-month rental period based on documentation supporting the medical necessity and appropriateness of the system.
CPAP may be approved for an initial 3-month period for adults if one of the following conditions are met:
• The Sleep Study Respiratory Disturbance Index (RDI) or Apnea/Hypopnea Index (AHI) is greater than or equal to 15 per hour
•The Sleep Study RDI or AHI is greater than 5 per hour and at least one of the following is true:
•Excessive daytime sleepiness (documented by either an Epworth greater than 10 or a Multiple Sleep Latency Test less than 6)
•Documented symptoms of impaired cognition, mood disorders, or insomnia
•Documented hypertension (systolic blood pressure greater than 140 mm Hg and/or diastolic blood pressure greater than 90 mm Hg)
•Documented ischemic heart disease
•Documented history of stroke
•Greater than 20 episodes of oxygen desaturation less than 85 percent during a full night sleep study
•Any one episode of oxygen desaturation less than 70 percent
One of the following AHI or oxygen saturation levels may be used for children:
•Polysomnography documentation of an AHI greater than 1
•An oxygen saturation of less than 92 percent, taken upon exertion and breathing room air.
Headgear, tubing, and filters used with client-owned positive airway pressure systems do not require prior authorization. Headgear, tubing, and filters are considered part of the rental and will not be reimbursed separately.
Humidifiers may be prior authorized when used with a CPAP system and with documentation of medical necessity.
Note: Supplies are limited to the amounts that an average client would use. If a client has an unusual need or situation, prior authorization for overages may be obtained with documentation of medical necessity.
|
