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KMAP BULLETIN: Coverage of CPAP and BiPAP

Date: 06/24/24

KMAP GENERAL BULLETIN 24106 (PDF)

Effective with dates of service on and after July 1, 2024, Medicaid will cover the following Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP) devices as medically necessary for children and adult members with Obstructive Sleep Apnea (OSA).

Sleep Study/Tests:

The diagnosis of OSA is made by clinical evaluation and confirmed by sleep testing. Unattended home sleep studies are indicated to confirm the diagnosis of sleep apnea as part of a comprehensive sleep evaluation. Attended sleep studies are indicated for individuals for whom unattended sleep studies are contraindicated.

ICD-10 Diagnosis Codes

G47.30

G47.31

G47.33

G47.34

G47.35

G47.36

G47.37

G47.39

 

 

Initial Coverage Criteria:

Accessories used with a Positive Airway Pressure (PAP) device are covered when the device's coverage criteria are met. If the criteria are not met, the accessories will be denied as not medically necessary.

I.            An E0601 device (single-level CPAP) is covered for the treatment of OSA if criteria A–C are met:

    A.     The member has an in-person clinical evaluation by the treating practitioner prior to the sleep test to assess the member for OSA.

    B.      The member has a sleep test (as defined below) that meets either of the following criteria (1 or 2):

        1.       The apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events or,

        2.       The AHI or RDI is 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:

            a.       Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or,

            b.       Hypertension, ischemic heart disease, or history of stroke.

            c.     The member and/or their caregiver have received instruction from the device supplier in the proper use and care of the equipment.

II.            An E0470 device (bi-level respiratory assist device without back-up rate) is covered for those members with OSA who meet criteria A–C above, in addition to criterion D:

    A.     An E0601 has been tried and proven ineffective based on a therapeutic trial conducted in a facility or home setting.

Code

Modifier

Rate*

Limitations

CPAP/BiPAP MACHINE

E0601

RR

$38.34

Rental

E0470

RR

$102.61

Rental

E0471

RR

$255.27

Rental

E0472

RR

$410.46

Rental

E0561

RR

$65.84

Rental

E0562

RR

$128.85

Rental

 

Code

Rate*

Limitations

CPAP/BiPAP MASK

A7027

$116.08

1 unit per 3 months

A7030

$84.18

1 unit per 3 months

A7034

$53.66

1 unit per year

A7044

$77.70

1 unit per year

 

Code

Rate*

Limitations

CPAP/BiPAP PARTS & ACCESSORIES

A4604

$37.29

1 unit per 3 months

A4618

$9.52

1 unit per year

A7028

$32.89

2 units per month

A7029

$14.57

2 units per month

A7031

$32.01

1 unit per month

A7032

$17.78

2 units per month

A7033

$14.78

2 units per month

A7035

$17.38

1 unit per 6 months

A7036

$9.81

1 unit per 6 months

A7037

$10.73

1 unit per 3 months

A7038

$1.93

2 units per month

A7039

$5.58

1 unit per 6 months

A7045

$10.98

1 unit per year

A7046

$12.83

1 unit per 6 months

 

Code

Rate*

Limitations

DEVICE MONITORING & MAINTENANCE REIMBURSEMENT

K0739

$11.00

8 units per year

 

* The rates noted in this bulletin are subject to future changes. Providers should check the Kansas Medical Assistance Program (KMAP) website for the most up-to-date rates.

Note: The CPAP device is covered for rental with prior authorization (PA) for a maximum of six months. When PA is requested beyond six months, the CPAP device is considered purchased at ten months.

Mask, tubing, headgear, chinstrap, and permanent filters are allowed with limitations as listed above. Replacements for these items before the one-year period is completed require documentation, including what happened to the previous item(s) and the reason(s) replacements are needed.

Note: The effective date of the policy is July 1, 2024. The implementation of State policy by the KanCare Managed Care Organizations (MCOs) may vary from the date noted in the KMAP bulletins. The KanCare Open Claims Resolution Log on the KMAP Bulletins page documents the MCO system status for policy implementation and any associated reprocessing completion dates once the policy is implemented.