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CPAP machine and sleep apnea

Is Preauth Required? Yes, preauth/prior-auth is required for the treatment/procedure- Continuous airway pressure (CPAP) device [may be used for either CPAP or APAP]. programs. Managed by Carelon Medical Benefits Management for Fully Insured and Vendor Program eligible members. No authorization required for members not eligible for vendor.

Will the claim be denied? A claim for a CPAP machine for the treatment of sleep apnea would typically require prior authorization justification. The justification should include that the patient is aged 19 or older, has an AHI of 5 or higher and is showing signs of excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease, or a history of stroke. If the patient has a contraindication to APAP or has failed APAP retitration, a split night study should be conducted to establish appropriate CPAP treatment parameters. If the criteria is not met, the claim may be denied.

When is the following treatment medically necessary for the condition specified? Treatment with CPAP is considered medically necessary for patients aged 19 and over when they demonstrate symptoms of Obstructive Sleep Apnea and when they demonstrate compliance with the therapy. Demonstration of compliance is required every 90 days for the first year of therapy and annually thereafter. Compliance is defined as either use of the CPAP device for at least 4 hours per night on 70% of nights during a consecutive 30 day period within the preceding 90 days or clinical evidence that demonstrates continued clinical benefit from use of the PAP device is submitted by the treating provider.

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