UM Guidelines

	Changed Clinical Indications include the following:
	Continuous positive airway pressure (CPAP) may be indicated for 1 or more of the following: [Initial Therapy (rental) request for 1 or more of the following conditions:] * Central sleep apnea, and CPAP ... Obesity hypoventilation syndrome, and CPAP ... Obstructive sleep apnea, and CPAP ... [Continued coverage (purchase) request for CPAP beyond the first three months of therapy when ALL of the following are met: In person clinical re-evaluation by the treating practitioner no sooner than the 31st day but no later than the 91st day Documentation that symptoms of obstructive sleep apnea are improved Objective evidence of adherence (adherence defined as use of CPAP 4 hours or more per night on 70% of nights during a consecutive thirty [30] day period anytime during the first three [3] months of initial usage) Replacement of CPAP device with 1 or more of the following: Within the 5 year reasonable useful lifetime (RUL) with documentation of loss, theft, or irreparable damage due to a specific incident After the 5 year reasonable useful lifetime (RUL) with ALL of the following: Documentation of an in person evaluation by treating practitioner Documentation that the patient continues to use and benefit from CPAP] *

References

1. CGS Administrators, LLC. (2024). Local Coverage Determination (LCD): Positive airway pressure (PAP) devices for the treatment of obstructive sleep apnea (L33718). Retrieved May 7, 2024 from https://www.cms.gov/