CPAP (Continuous Positive Airway Pressure)
Medicare covers a single level CPAP device, for initial coverage, if the patient, during sleep, temporarily stops breathing, called obstructive sleep apnea. Medicare requires an overnight sleep study performed in a sleep laboratory (the study is called a polysomnography or PSG). What that study has to show is either of the following criteria using the Apnea Hypopnea Index (AHI) is met:
- The AHI is > 15 events per hour OR
- The AHI is > 5 to 14 events per hour with documented symptoms of:
- Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia or
- Hypertension, ischemic heart disease, or history of stroke.
Medicare covers the use of the CPAP for up to 3 months. If a patient requires the CPAP beyond 3 months, no sooner than the 61st day after beginning use of the CPAP, the supplier must be notified by the doctor or the patient that there will be continued use beyond the three-month period. Medicare covers accessories used with the CPAP if the CPAP is covered by Medicare: masks; cannulas; tubing and other necessary supplies.
An order (prescription) must be on file with the supplier. It must be signed and dated by the treating doctor.
CPAPs are in the Capped Rental category of DME; that means you may choose to rent or purchase a CPAP.
After three months of use, you will be required to verify if you are benefiting from using the device and how many hours a day you are using the machine.
What is AHI?
The AHI is THE primary index for the severity of sleep apnea. Apneas are usually measured during sleep (preferably in all stages of sleep). AHI is the number of apneas and/or hypopneas per hour of sleep or per hour of study time (Medicare requires at least two hours of sleep be analyzed). The greater the apnea index, the more severe the apnea:
- 0 to 4 apneas an hour is considered normal
- 5-14 is considered mild sleep apnea
- 15-30 is considered moderate sleep apnea
- Greater than 30 is considered severe
