Bi-level Positive Airway Pressure (BIPAP) (E0470/E0471) Prior Authorization Request Form
Customize your policy alerts
Sign up for all Blue Cross Blue Shield - North Carolina policy alerts
Know when Blue Cross Blue Shield - North Carolina releases new policies or updates existing guidance.
Monitor payer policy activity
Form and medical criteria used by Blue Cross Blue Shield of North Carolina to authorize rental or purchase of bi-level positive airway pressure devices (E0470, E0471) for breathing-related sleep disorders; intended for ordering providers and durable medical equipment vendors completing PA requests for NC members.
No material clinical or coverage changes in this revision.
Coverage criteria and indications
Purchase after rental criteria
Purchase after 3-month rental is considered when documentation shows continued benefit and compliance.
This form is intended only for prior authorization requests for HCPCS E0470 or E0471. If the request is not for E0470 or E0471, the form must not be used.
Requests that do not document the objective clinical criteria required for the selected indication may be denied. Examples include absent or insufficient arterial blood gas evidence (e.g., failure to document awake PaCO2 thresholds or >7 mmHg worsening when specified), missing qualifying sleep oximetry demonstrating SpO2 <88% for >5 minutes with a minimum recording time of 2 hours, omitted pulmonary function or respiratory muscle testing (such as maximal inspiratory pressure <60 cm H2O or FVC <50% when applicable), lack of a documented CPAP trial when required for COPD indications, or missing compliance documentation for purchase after rental (e.g., use ≥4 hours/24 hrs at day 61).
HCPCS codes and measurable thresholds
What providers and vendors must do
Prior CPAP and E0470 Trial Period
For COPD-related indications, CPAP must be considered and ruled out prior to initiating E0470 rental. If an E0470 is issued and an E0471 purchase/replacement is requested, the E0471 will be considered only after meeting the specified trial period criteria: an E0471 (purchase or replacement) is covered only if both criteria are met at a time no sooner than 61 days after initial issue of an E0470.
Required Demographic and Device Documentation
Complete and submit required member, ordering physician, and vendor information and document the requested HCPCS code(s). Include objective clinical data supporting the medical necessity of BIPAP: ABG PaCO2 values (awake and, if applicable, during sleep), sleep oximetry with recording times and oxygen/FIO2 used, spirometry (FEV1/FVC, FVC percent predicted), maximal inspiratory pressure (MIP), diagnosis codes, and vendor details.
- Required demographic/vendor fields: Member name, DOB, Member ID, Contact name/phone, Ordering physician name, office phone/fax, NPI, Vendor name/phone/fax, Vendor NPI
- HCPCS code(s) (REQUIRED) and ICD-10 code(s)
- Objective documentation: ABG PaCO2 (awake on prescribed FIO2), sleep oximetry showing % saturation and recording duration (minimum 2 hours; <88% for >5 minutes), spirometry (FEV1/FVC, FVC % predicted), maximal inspiratory pressure, and compliance data if requesting purchase after rental
Missing or Insufficient Documentation May Delay or Deny
Incomplete or missing documentation may delay review or lead to denial. Commonly insufficient items include omitted HCPCS code(s), absent ABG PaCO2 values, missing sleep oximetry details (duration, oxygen/FIO2 used, and whether desaturation is due to obstructive events), lack of spirometry or MIP data, and absent vendor or ordering physician identifiers. Provide full copies of facility-based PSG/HST reports, compliance downloads (for purchase after rental), and explicit notation whether CPAP was tried and ruled out when applicable.
- Incomplete form fields (member, physician, vendor)
- Missing or incomplete ABG, sleep oximetry, spirometry, or MIP results
- For E0471 after E0470: missing documentation of 61-day trial, ABG and oximetry while using E0470
- If requesting purchase after 3-month rental: provide compliance chip/download showing ≥4 hours/night use and physician re-evaluation documentation
Clinical background
Bi-level positive airway pressure devices (BIPAP) are prescribed to treat several breathing-related sleep disorders including restrictive thoracic or neuromuscular disorders, severe COPD with chronic hypercapnia, central or complex sleep apnea, and hypoventilation syndromes. The form focuses on objective physiologic measures to support medical necessity: arterial blood gas PaCO2 thresholds while awake on the member's prescribed FIO2, sleep oximetry demonstrating sustained desaturation (SpO2 <88% for >5 minutes with minimum 2-hour recording), and disease-specific tests such as maximal inspiratory pressure or spirometry (FEV1/FVC and FVC percent predicted). For COPD-related indications, a CPAP trial should be considered and ruled out prior to BIPAP initiation, and escalation to an E0471 may require additional evidence of worsening PaCO2 or a minimum trial period of an E0470 device.
Definitions and specific indication thresholds
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.