NCD 240.4: Continuous Positive Airway Pressure (CPAP) for Obstructive Sleep Apnea
Medicare covers CPAP for OSA when diagnosed by appropriate sleep testing AND patient meets adherence criteria during 90-day trial period.
What's covered
- CPAP equipment (E0601) for OSA confirmed by PSG (95810) or HSAT (95800)
- Initial 90-day trial
- Ongoing rental conversion to purchase if adherence met
Coverage criteria
- AHI ≥15 OR AHI ≥5 with symptoms (excessive daytime sleepiness, HTN, ischemic heart disease, stroke history)
- PSG or HSAT result
- 90-day adherence: ≥4 hours/night on 70% of nights in 30 consecutive days during trial period
- Face-to-face clinical re-evaluation between days 31-91 confirming adherence + benefit
Exclusions
- BiPAP without documented CPAP intolerance
- Coverage discontinued if adherence criteria not met during trial
Common denial patterns
- Adherence not documented from device data download
- Face-to-face re-eval not done in correct window
- BiPAP billed without CPAP intolerance documentation
- HSAT result without proper supervision documentation
Appeal citation
NCD 240.4 (CPAP for OSA). Cite documented AHI, adherence data (≥4hr/night, ≥70% of nights), and face-to-face re-evaluation.
Frequently asked questions
What does Medicare NCD 240.4 cover?
Medicare covers CPAP for OSA when diagnosed by appropriate sleep testing AND patient meets adherence criteria during 90-day trial period.
What are the coverage criteria?
AHI ≥15 OR AHI ≥5 with symptoms (excessive daytime sleepiness, HTN, ischemic heart disease, stroke history); PSG or HSAT result; 90-day adherence: ≥4 hours/night on 70% of nights in 30 consecutive days during trial period; Face-to-face clinical re-evaluation between days 31-91 confirming adherence + benefit.
What is excluded?
BiPAP without documented CPAP intolerance; Coverage discontinued if adherence criteria not met during trial.
How do I cite this NCD in an appeal?
NCD 240.4 (CPAP for OSA). Cite documented AHI, adherence data (≥4hr/night, ≥70% of nights), and face-to-face re-evaluation.
Other Respiratory/DME NCDs
Sources
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