01The billing team should confirm the chart meets the criteria for the condition before billing a bilevel PAP device.
02For restrictive thoracic disorders, the chart should show symptoms of sleep-associated hypoventilation and clinically significant hypoxemia, either an awake arterial blood gas PaCO2 of at least 45 mm Hg on the prescribed FIO2 or sleep oximetry at or below 88 percent for at least 5 minutes over a recording of at least 2 hours on the member's usual FIO2.
03For severe COPD, the chart should show a PaCO2 of at least 52 mm Hg while awake, sleep oximetry at or below 88 percent for at least 5 cumulative minutes over at least 2 hours on 2 liters per minute or the prescribed FIO2 (whichever is higher), and documentation that obstructive sleep apnea was considered and ruled out before therapy.
04For central or complex sleep apnea, a complete inpatient, attended polysomnogram must document the diagnosis and significant improvement with the settings prescribed for home use.
05For obstructive sleep apnea, the member must meet the CPAP criteria and have had CPAP tried and proven ineffective or not tolerated.
06Sleep testing must be a facility-based polysomnogram (Type I) or an inpatient, home or other qualifying sleep test (Types II, III, IV or Other).
07According to DME MAC policy, arterial blood gas, sleep oximetry and polysomnographic studies may not be performed by the DME supplier.
08Physician reassessment of benefit and adherence should occur within 60 days of initiation, and members should be re-evaluated after 2 to 3 months.
09Continued coverage beyond 3 months requires records showing compliant use (an average of 4 hours per 24-hour period) and that the member is benefiting.
10For ventilators with noninvasive interfaces, the chart must document a neuromuscular disease, thoracic restrictive disease or chronic respiratory failure from COPD where interruption or failure of respiratory support would lead to death.
11For a multi-function home ventilator, the chart must support the need for more than one additional function (oxygen concentrator, cough stimulator, suction pump or nebulization).
12Liners used with a PAP mask are comfort or convenience items and should not be billed as replacement features of a PAP mask.
13Electrical generators that power respirators or bilevel PAP devices do not meet the definition of DME.