Medicare Guidelines for CPAP

1) The patient must have a face to face evaluation with a physician of their choice. At this appointment there must be documentation of symptoms of OSA, a completed Epworth Sleepness Scale, BMI (Body Mass Index), neck circumference, and a focused cardiopulmonary and upper airway system evaluation. This appointment with the physician must always proceed the baseline sleep study.

2) If the patient is currently using CPAP and becomes a medicare patient, the first baseline must meet Medicare criteria. It does not matter how long ago this baseline was performed. If the patient did not have enough OSA then the patient must repeat #1 and re-qualify for CPAP. If the prior baseline met Medicare criteria, the first face to face with the physician, after going on Medicare, must include documentation about the patients compliance of CPAP according to Medicare guidelines.  

3) After 3 months, if a patient did not prove nightly usage of CPAP, Medicare will not cover the cost. If the patient wants Medicare to cover the CPAP again they must start with a new face to face evaluation prior to the CPAP.

Medicare Coverage of CPAP at Home

After the patient starts CPAP treatment at home there has to be documentation of patient compliance. This is done after 31 days but before 90 days of usage. They must have a download of the CPAP usage and a face to face re-evaluation with their physician. Their physician must document that the patients symptoms have improved. Adherence to CPAP is defined as usage greater or equal to 4 hours per night on 70% of nights during a consecutive 30 days anytime during the first 3 months of initial usage.

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