CommercialCoverageHigh impact
Continuous Positive Airway Pressure (CPAP) and Auto-Adjusting Positive Airway Pressure (APAP) Devices - (Effective Date - 2026-10-15) 1.01.06
Excellus BlueCross BlueShield·NY · Sleep Medicine, Pulmonology, Internal Medicine +1 more·Sleep Medicine
Effective date
Oct 15, 2026
We identified it
Jul 16, 2026
Summary
Excellus BlueCross BlueShield updated its CPAP/APAP device policy (effective Oct 15, 2026) with stricter medical necessity criteria for initial 90-day trials, new compliance requirements (70% usage over 4+ hours/night for 30 days), and clarified non-coverage for snoring-only cases, cleaning devices (SoClean), and cosmetic replacements. Billing teams must enforce these criteria for claim submission and prior authorization decisions.
Action Required
By October 15, 2026: Billing team must update prior authorization workflows to enforce new CPAP/APAP medical necessity criteria in billing system. (1) Require providers to submit PSG/HST results documenting AHI/RDI thresholds (>5 and <15 with symptoms, OR ≥15 events/hour) before initial authorization. (2) For continuation claims past 90 days, require documented proof of compliance (70% nights used, 4+ hours per 24-hour period, consecutive 30-day period) AND improved AHI/symptom resolution. (3) Add edits to deny claims for snoring-only diagnoses, SoClean/cleaning device requests (A9279 accessories), and cosmetic replacements of functioning equipment. (4) For repair/replacement requests, require manufacturer warranty documentation and attestation of patient compliance. (5) Flag and deny any DME claims involving patient neglect, theft, abuse, or when alternative insurance coverage exists. Update provider communication materials and encounter forms to clarify these requirements. Failure to implement will result in claim denials and potential compliance issues with Excellus.