DME MACs issue policy reminder for CPAP

Friday, July 18, 2014

WASHINGTON – The DME MACs have issued a policy reminder to providers about CPAP therapy after a review of recent appeals identified denials associated with lack of compliance with requirements for continued coverage after the first three months of rental. At the end of the initial rental period, additional requirements must be met for rental and payments to continue: the treating physician must meet the beneficiary in person between the 31st and 91st days after initiating therapy for a re-evaluation documenting the benefits from PAP therapy and the physician must include objective evidence of the beneficiary’s adherence to the therapy in the medical record. Beneficiaries who fail the 12-week trial may re-qualify if they have a face-to-face re-evaluation to determine why they didn’t respond to therapy and if they repeat a sleep study. Also in the reminder: If an E0601 device is ineffective, substitution with an E0470 does not change the length of the trial if there are fewer than 30 days remaining; if there are more than 30 days remaining, the re-evaluation must be done between the 31st and 91st days and documentation of adherence to the E0470 device must be completed before the 91st day.