Continuous Positive Airway Pressure
WOPD (Written Order Prior To Delivery) or Prescription
Face To Face Examination
Medical Records:
The apnea-hypopnea index (AHI) is defined as the average number of episodes of apnea and hypopnea per hour of sleep without the use of a positive airway pressure device. For purposes of this policy, respiratory effort related arousals (RERAs) are not included in the calculation of the AHI. Sleep time can only be measured in a Type I (facility based polysomnogram) or Type II sleep study (see descriptions below).
The respiratory disturbance index (RDI) is defined as the average number of apneas plus hypopneas per hour of recording without the use of a positive airway pressure device. For purposes of this policy, respiratory effort related arousals (RERAs) are not included in the calculation of the RDI. The RDI is reported in Type III, Type IV, and Other home sleep studies.
If the AHI or RDI is calculated based on less than 2 hours of sleep or recording time, the total number of recorded events used to calculate the AHI or RDI (respectively) must be at least the number of events that would have been required in a 2 hour period (i.e., must reach 30 events without symptoms or 10 events with symptoms).
In this policy, the term PAP (positive airway pressure) device will refer to both a single-level continuous positive airway pressure device and a bi-level respiratory assist device without back-up rate when it is used in the treatment of obstructive sleep apnea.
A single-level continuous positive airway pressure device is covered for the treatment of obstructive sleep apnea (OSA) if criteria A – C are met:
- The beneficiary has a face-to-face clinical evaluation by the treating practitioner prior to the sleep test to assess the beneficiary for obstructive sleep apnea.
- The beneficiary has a sleep test (as defined below) that meets either of the following criteria (1 or 2):
- The apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or,
- The AHI or RDI is 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, or insomnia; or,
- Hypertension, ischemic heart disease, or history of stroke.
- The beneficiary and/or their caregiver have received instruction from the supplier of the device in the proper use and care of the equipment.
A bi-level respiratory assist device without back-up rate is covered for those beneficiaries with OSA who meet criteria A-C above, in addition to criterion D: An single-level continuous positive airway pressure device has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting.
