Policy Reminder – Positive Airway Pressure Devices – Beneficiaries Entering Medicare

Recently, we have received multiple questions with regard to billing PAP devices when a beneficiary is transitioning to traditional FFS Medicare from a Medicare Advantage plan or is recently eligible for Medicare coverage.

When a beneficiary receiving a PAP device from another payer (including a Medicare Advantage plan) becomes eligible for the Medicare FFS program, the first Medicare claim for that PAP device is considered a new initial Medicare claim for the PAP device. Even if there is no change in the beneficiary’s medical condition, the beneficiary must meet all coverage, coding and documentation requirements for the PAP device in effect on the date of service of the initial Medicare claim. The “Coverage Indications, Limitations, and/or Medical Necessity” section of the LCD for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea does include specific information for beneficiaries entering Medicare, and who received a PAP device prior to enrollment in FFS Medicare.

The LCD states the following:

BENEFICIARIES ENTERING MEDICARE:

For beneficiaries who received a PAP device prior to enrollment in fee for service (FFS) Medicare and are seeking Medicare coverage of either rental of the device, a replacement PAP device and/or accessories, both of the following coverage requirements must be met:

1. Sleep test – There must be documentation that the beneficiary had a sleep test, prior to FFS Medicare enrollment, that meets the Medicare AHI/RDI coverage criteria in effect at the time that the beneficiary seeks Medicare coverage of a replacement PAP device and/or accessories; and,
2. Clinical Evaluation – Following enrollment in FFS Medicare, the beneficiary must have a face-to-face evaluation by their treating physician who documents in the beneficiary’s medical record that:
   1. The beneficiary has a diagnosis of obstructive sleep apnea; and,
   2. The beneficiary continues to use the PAP device.

If either criteria 1 or 2 above are not met, the claim will be denied as not reasonable and necessary.