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Policy No: 127

Originally Created: 03/01/2017

Section: Administrative

Last Reviewed: 02/01/2019

Last Revised: 02/01/2018

Approved:  02/21/2019

Effective:  04/01/2019

This policy applies only to the supplies/accessories used with PAP devices.

Definitions

Positive Airway Pressure (PAP)

A mode of respiratory ventilation used primarily in the treatment of sleep apnea.

Policy Statement

Accessories used with PAP devices may be covered when criteria for the device are met. Our health plan utilizes Centers for Medicare & Medicaid Services (CMS) Local Coverage Determinations (LCD) to determine the reasonable and necessary maximum quantities and frequencies for PAP accessory purchases. Our health plan has, at our discretion, increased the CMS maximum quantities and/or frequencies as we deemed appropriate.

When the total units of service for a Healthcare Common Procedure Coding System (HCPCS) code has exceeded the maximum allowed within the specified time frame, our health plan will allow up to that limit and deny the remaining units. Our health plan will allow up to a 10-day grace period.

Example: Two (2) units of HCPCS A7029 are purchased on 4/1/2017. The member may receive up to four (4) additional units of HCPCS A7029 prior to 6/30/2017, for a total of six (6) units of HCPCS A7029 purchased within a 3 month/90 day period.

Billing of PAP accessories must be based on prospective, not retrospective, use. Suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. This will be done to ensure that the items remain reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes or modifications to the order. Items delivered without a valid, documented refill request from the beneficiary will be denied as not reasonable and necessary.

HCPCS Code Code Description Maximum Units Frequency
A4604 Tubing with integrated heating element for use with positive airway pressure device 1 3 months/90 days
A7027 Combination oral/nasal mask, used with continuous positive airway pressure device, each 1 3 months/90 days
A7028 Oral cushion for combination oral/nasal mask, replacement only, each 6 3 months/90 days
A7029 Nasal pillows for combination oral/nasal mask, replacement only, pair 6 3 months/90 days
A7030 Full face mask used with positive airway pressure device, each 1 3 months/90 days
A7031 Face mask interface, replacement for full face mask, each 3 3 months/90 days
A7032 Cushion for use on nasal mask interface, replacement only, each 6 3 months/90 days
A7033 Pillow for use on nasal cannula type interface, replacement only, pair 6 3 months/90 days
A7034 Nasal interface (mask or cannula type) used with positive airway pressure device, with Or without head strap 1 3 months/90 days
A7035 Headgear used with positive airway pressure device 1 6 months/180 days
A7036 Chinstrap used with positive airway pressure device 1 6 months/180 days
A7037 Tubing used with positive airway pressure device 1 3 months/90 days
A7038 Filter, disposable, used with positive airway pressure device 6 3 months/90 days
A7039 Filter, non-disposable, used with positive airway pressure device 1 6 months/180 days
A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, each 1 6 months/180 days

 

References

Centers for Medicare & Medicaid Services (CMS) Local Coverage Determination (LCD), L33718, Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea

Centers for Medicare & Medicaid Services (CMS) Local Coverage Determination (LCD), L33800, Respiratory Assist Devices

Cross References

None

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.