Durable Medical Equipment, Prosthetics, Orthotics and Supplies

Clinicians: Are You Ordering PAP Devices and Related Accessories for Your Patients?

Medicare can make payment for PAP devices and related accessories when the patient’s medical record shows the patient has OSA and meets medical documentation, test results and health conditions as specified in the CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Part 4, (1022 KB) Section 240.4 and the DME LCD L33718.

Medicare’s coverage for PAP devices and accessories begins with a 12-week trial period. In order for a DME supplier to provide the PAP device, the following must take place:

  • You must have an in-person evaluation with your patient to discuss any sleep-related issues they are experiencing. During this encounter, you should document pertinent information such as signs and symptoms of sleep disordered breathing (for example, patient-reported episodes of snoring, daytime sleepiness, observed apneas, choking or gasping during sleep and morning headaches), the duration of those symptoms and may ask the patient to complete a validated sleep hygiene inventory (i.e., Epworth Sleepiness Scale). Pertinent physical examination findings should also be documented, such as the patient’s body mass index, neck circumference, upper airway exam and cardiopulmonary exam.
  • Following the in-person evaluation, you must order a facility-based polysomnogram (Type I study) or an inpatient hospital-based or home-based sleep test (Type II, III, IV or other) which meet the coverage and payment requirements outlined in the CMS IOM, Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, the applicable A/B MAC LCDs, and A/B MAC Billing and Coding articles. This test must be conducted using an FDA-approved device. 
  • The sleep study results must show an AHI or RDI greater than or equal to 15 events per hour with a minimum of 30 events or an AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of excessive daytime sleepiness, impaired cognition, mood disorders, insomnia or hypertension, ischemic heart disease or history of stroke. Note that for Medicare, hypopnea is defined as an abnormal respiratory event lasting at least ten seconds associated with at least a 30 percent reduction in thoracoabdominal movement or airflow as compared to baseline and with at least a four percent decrease in oxygen saturation. In addition, RERAs are not included in the AHI/RDI calculation. This sleep study must take place on or after the date of the in-person encounter documenting signs and symptoms of OSA. The sleep test must then be interpreted by a physician/nonphysician practitioner who meets the credentialing requirements as outlined in LCD L33718 (i.e., current certification in Sleep Medicine by the American Board of Sleep Medicine).
  • If the sleep test interpretation indicates a diagnosis of OSA, the sleep test indicates the AHI/RDI threshold requirement is met, and you determine the patient would benefit from PAP therapy, you may order a PAP device and related accessories. When your patient arrives at the DME supplier, their staff will fit them with a PAP device, provide them with the appropriate accessories (i.e., mask, cushions, filters and tubing, etc.) and review the use and care of the equipment with them

The preceding steps will allow the DME supplier to bill Medicare for three rental months of the PAP device and related accessories.

Between the 31st and 91st day after initiating PAP therapy, your medical record documentation must show a face-to-face reevaluation with your patient to assess the benefit of PAP therapy. The documentation must support the patient’s symptoms of OSA have decreased and how the PAP device has helped your patient. Your medical record documentation must also demonstrate the patient is adhering to the therapy and that you have reviewed the adherence documentation. Adherence to therapy is defined as usage of the PAP device greater than or equal to four hours per night on 70 percent of nights during a consecutive 30-day period any time during the first three months of initial usage. Documentation of the patient’s adherence to PAP therapy can be accomplished by your review of information maintained on the PAP device via visual inspection, data downloaded from the PAP device, or access from web-based sites with data transmitted from the PAP device. This information must be maintained in your patient’s medical records and made available upon request.

The in-person reevaluation does not have to be completed by the medical professional who ordered the PAP device. It can be completed by another physician or nonphysician practitioner following the patient. For example, if a sleep specialist ordered the PAP device, but the patient goes to their primary care physician two months later for reevaluation, that would be acceptable and meet the Medicare requirement for the reevaluation.

Documentation Reminders

The SWO for the PAP device must contain the following:

  • Beneficiary’s name or MBI
  • Order date
  • Description of item(s) ordered
  • Quantity to be dispensed, if applicable
  • Treating practitioner name or NPI
  • Treating practitioner signature

The DME supplier will most likely send you a SWO for the PAP accessories which has been prepared for your review and signature. Please review, sign and date the SWO in a timely manner so the DME supplier can file claims to the Medicare Program.

Following these coverage guidelines will help your patients and the Medicare Program by verifying that there is medical documentation to support the provision of a PAP device and allow your patient to receive the therapy needed to treat OSA. Your assistance will allow Medicare to pay claims appropriately and ensure that your patient receives the DMEPOS items you have prescribed.

For coverage and limitations of these supplies review the Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea LCD L33718 and Policy Articles A52467 and the Standard Documentation Requirements Policy Article A55426.

Reviewed 11/21/2024