July 15, 2008
Continuous Posititive Airway Pressure System (CPAP) LCD - Revised
The CPAP policy has been revised to reflect the Centers for Medicare & Medicaid Services (CMS) national coverage determination (NCD) on the use of home sleep tests to qualify patients with obstructive sleep apnea (OSA) for Positive Airway Pressure (PAP) devices. Certain provisions of the policy are effective for dates of service on or after March 13, 2008, the effective date of the NCD; however, certain requirements will be prospectively implemented for dates of service on or after September 1, 2008.
Since some LCD provisions have differing effective dates, the criteria that apply for coverage are dependent on the date the PAP device was dispensed. There are 3 critical dates:
- If the PAP device was dispensed prior to March 13, 2008, the initial coverage criteria and coverage criteria for use beyond the first 3 months must meet the CPAP policy requirements that were effective January 1, 2008.
- If the PAP device was dispensed after March 13, 2008 but before September 1, 2008, the initial coverage criteria and the criteria for coverage after the first 3 months must meet the requirements in this revised PAP policy that reflect the CMS NCD requirements outlined in CMS Internet-Only Manual Pub. 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Part 4, Section 240.1.
- If the PAP device is dispensed on or after September 1, 2008, all requirements in this revised PAP policy must be met.
If the PAP device was dispensed prior to September 1, 2008, the KX modifier may be added to the claim if:
- The initial coverage criteria in effect at the time were met; and,
- The criteria for coverage after the first 3 months that were in effect at the time were met; and,
- The patient continues to compliantly use the device.
It should also be noted that the name of the policy has changed to Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea. The change reflects the addition of coverage criteria for respiratory assist devices (E0470 and E0471) when used to treat OSA. With the addition of these coverage criteria to the PAP policy, provisions related to the use of codes E0470 and E0471 for OSA were removed from the Respiratory Assist Device (RAD) policy. A revision of the RAD policy reflecting this change will be published in the near future.
Supplier should review the entire PAP policy @ http://www.cignagovernmentservices.com/jc/coverage/LCDinfo.html for additional information on the coding, coverage and documentation requirements for these devices.
