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August 23, 2021

Clinicians! Are You Ordering PAP Devices and Related Accessories for Your Patients?

Medicare can make payment for Positive Airway Pressure (PAP) devices and related accessories when the patient's medical record shows the patient has Obstructive Sleep Apnea (OSA) and meets medical documentation, test results, and health conditions as specified in the CMS Internet-Only Manual (IOM) Publication 100-03, Section 240.4 and the durable medical equipment (DME) Local Coverage Determination (LCD) L33718.

Medicare's coverage for PAP devices and accessories begins with a 12-week trial period. In order for a DME supplier to provide the PAP device, the following must take place:

  • You must have an in-person evaluation with your patient to discuss any sleep-related issues they are experiencing. During this encounter, you should document pertinent information such as signs and symptoms of sleep disordered breathing (for example, patient-reported episodes of snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, and morning headaches), the duration of those symptoms, and may ask the patient to complete a validated sleep hygiene inventory (such as the Epworth Sleepiness Scale). Pertinent physical examination findings should also be documented, such as the patient’s body mass index, neck circumference, upper airway exam, and cardiopulmonary exam.
  • Following the in-person evaluation, you must order a facility-based polysomnogram (Type I study) or an inpatient hospital-based or home-based sleep test (Type II, III, IV, or Other) that meets the coverage and payment requirements outlined in the CMS National Coverage Determination (NCD) 240.4.1 (CMS Pub.100-03, Chapter 1, Part 4), the applicable A/B MAC LCDs, and A/B MAC Billing and Coding articles. This test must also be one that is FDA-approved as a diagnostic device.
  • The sleep study results must show an Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) greater than or equal to 15 events per hour with a minimum of 30 events, or an AHI or RDI 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, insomnia or hypertension, ischemic heart disease, or history of stroke. Note that for Medicare, hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds associated with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% decrease in oxygen saturation. In addition, respiratory effort-related arousals (RERAs) are not included in the AHI/RDI calculation. This sleep study must take place on or after the date of the in-person encounter documenting signs and symptoms of OSA.
  • If the sleep test interpretation indicates a diagnosis of OSA and you determine that the patient would benefit from PAP therapy, you may order a PAP device and related accessories. When your patient arrives at the DME business, their staff will fit them with a PAP device, provide them with the appropriate accessories (such as a humidifier, mask, and tubing), and review the use and care of the equipment with them.

The preceding steps will allow the DME supplier to bill Medicare for three rental months of the PAP device and related accessories.

Between the 31st and 91st day after initiating PAP therapy, your medical record documentation must show an in-person re-evaluation of the patient to assess the benefit of PAP therapy. The documentation must support that the patient’s symptoms of OSA have improved and may include additional details regarding how the PAP device has helped your patient. Your medical record documentation must also demonstrate the patient is adhering to the therapy and that you have reviewed this adherence. Adherence to therapy is defined as usage of the PAP device greater than or equal to 4 hours per night on 70% of nights during a consecutive thirty-day period any time during the first three months of initial usage. Documentation of the patient's adherence to PAP therapy can be accomplished by your review of information maintained on the PAP device via visual inspection, data downloaded from the PAP device, or access from web-based sites with data transmitted from the PAP device. This information must be maintained in your patient's medical records and made available upon request.

The in-person re-evaluation does not have to be completed by the medical professional who ordered the PAP device. It can be completed by another physician or non-physician practitioner following the patient. For example, if a sleep specialist ordered the PAP device, but the patient goes to their primary care physician two months later, that would be acceptable and meet the Medicare requirement for the re-evaluation.

Documentation reminders:

The standard written order (SWO) for the PAP device must contain the following:

  • Beneficiary's name or Medicare Beneficiary Identifier (MBI)
  • Order Date
  • Description of the item(s) ordered
  • Quantity to be dispensed, if applicable
  • Treating Practitioner Name or NPI
  • Treating practitioner's signature

The DME supplier will most likely send you an SWO, for the PAP accessories, which they have prepared for your review and signature. Please review and sign that SWO in a timely manner so the DME supplier can file claims to the Medicare program.

Following these coverage guidelines will help your patient and the Medicare program by verifying that there is medical documentation to support the provision of a PAP device and allow your patient to receive the therapy needed to treat OSA. Your assistance will allow Medicare to pay claims appropriately and ensure that your patient receives the DMEPOS items you have prescribed.

For coverage and limitations of these supplies review Local Coverage Determination (LCD) L33718External Website and Policy Articles A52467External Website and A55426External Website

Note: During the duration of the COVID-19 Public Health Emergency (PHE), the face-to-face encounter requirements do not apply, and the clinical indications for coverage found in respiratory, infusion pump, and therapeutic continuous glucose monitor NCDs or LCDs will not be enforced. Treating practitioners and suppliers must still:

  • Provide a standard written order (SWO) for all items.
  • Ensure that the items or services are reasonable and necessary;
  • Continue documenting the medical necessity for all services. Accordingly, the medical record must be sufficient to support payment for the services billed (that is, the services were actually provided, were provided at the level billed, and were medically necessary);
  • Make documentation available, upon request.

This enforcement discretion will only apply during the COVID-19 PHE.


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