Medicare Guidelines for CPAP
Medicare provides benefits for CPAP (continuous positive airway pressure) devices and accessories, used mainly in the treatment of sleep apnea. Effective April 1, 2002, the Centers for Medicare and Medicaid Services broadened coverage criteria for CPAP, including coding, coverage, payment and documentation guidelines.
Other People Are Reading
-
Qualifications
-
To qualify for a CPAP device under Medicare, you are required to undergo a sleep study performed in an accredited sleep facility, and you must experience the following according to the apnea-hypopnea index (AHI): greater than 15 episodes of respiratory disturbance, or five to 14 episodes per hour, with documentation of daytime sleepiness, impaired mental function, mood disorders or insomnia. Or if these four apnea symptoms don't exist, then high blood pressure, heart disease or stroke must be present.
Additional Requirements
-
In addition, you must have a diagnostic study, titration study (a monitored sleep evaluation that includes a nasal mask) and a signed prescription from a licensed physician.
-
Documentation
-
Your CPAP supplier is required to keep the following information on file: a physician-signed order detailing the needed CPAP equipment and accessories and documentation of medical necessity. A certificate of medical necessity (CMS) is no longer required per policy revision.
Coverage
-
Medicare will cover 80 percent of CPAP equipment and accessories according to its fee schedule, requiring a 20 percent co-pay or additional coverage by a secondary insurer.
Equipment
-
Medicare guidelines dictate that CPAP machines cannot be purchased directly. Instead, equipment is rented for a 13-month period, after which it is converted to a purchasing schedule and the patient assumes ownership.
-
