CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

Bi-level Positive Airway Pressure (BIPAP) (E0470/E0471) Prior Authorization Request Form

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.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyBIPAP (E0470/E0471) Prior Authorization Request Form (coverage criteria)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed PA form with required clinical documentation (ABG PaCO2, sleep oximetry, spirometry/MIP, ICD-10, HCPCS code) and compliance data for purchase requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4indication sections

>=61dE0471 replacement interval

4 hrs/dayrequired device use

45/52PaCO2 thresholds

Coverage criteria and indications

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Purchase after rental criteria

Purchase after 3-month rental is considered when documentation shows continued benefit and compliance.

Purchase after 3-month rental: 1) Documentation in the member's medical record reflects progress of relevant symptoms; AND 2) Compliance chip/download shows consistent device use ≥4 hours per 24 hours at the day 61 re-evaluation; AND 3) Physician documents the member is compliant and benefiting from device use at the day 61 re-evaluation.

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

Requested HCPCS CodesHCPCSCovered

E0470	Bi-level airway pressure device, without backup rate
E0471	Bi-level airway pressure device, with backup rate

Arterial blood gas (PaCO2) thresholds

Awake PaCO2 threshold (restrictive/hypoventilation)Awake arterial PaCO2 > 45 mmHg (measured while awake and breathing the member's prescribed FIO2)

Awake PaCO2 threshold (severe COPD)Awake arterial PaCO2 > 52 mmHg (measured while awake and breathing the member's prescribed FIO2)

Worsening PaCO2 criterionChange in PaCO2 > 7 mmHg compared to baseline (sleep or immediate-awakening ABG) indicating clinically significant worsening

Sleep oximetry threshold

Oximetry desaturation thresholdOxygen saturation < 88% for > 5 minutes of nocturnal recording time

Minimum recording timeMinimum recording time for qualifying sleep oximetry is 2 hours

Measurement conditionOximetry must be recorded while the member is breathing the prescribed FIO2 or oxygen (when applicable)

Maximal inspiratory pressure

Maximal inspiratory pressure (MIP)Maximal inspiratory pressure < 60 cm H2O

ApplicabilityMIP criterion applies specifically for neuromuscular disease within the Restrictive Thoracic Disorders indication

DocumentationMIP must be documented in the member's medical record as part of the Restrictive Thoracic Disorders section

Forced vital capacity

Forced vital capacity (FVC)Forced vital capacity < 50% predicted

ApplicabilityFVC criterion applies for neuromuscular disease within the Restrictive Thoracic Disorders indication

Measurement contextFVC should be reported as percent predicted and documented in the medical record

Compliance usage

Compliance usage threshold for purchase after rentalConsistent device use ≥ 4 hours per 24 hours at the day-61 re-evaluation

Documentation requiredProvide compliance chip/download showing ≥4 hours/24 hrs at day 61 for purchase after a 3-month rental

Physician attestationPhysician must document that the patient is compliant with and benefiting from device use at the day-61 re-evaluation

What providers and vendors must do

Prior Authorization

Prior Authorization Required

Prior authorization is required for devices billed as HCPCS E0470 or E0471. Use the Bi-level Positive Airway Pressure (BIPAP) PA Request Form only for requests for these codes.

Affected codes: E0470, E0471
If request is not for E0470 or E0471, do not use this form

Prior Authorization

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.

CPAP considered and ruled out prior to initiating E0470 when COPD is significant
E0471 allowed only after >= 61 days from initial E0470 and when PaCO2 and sleep oximetry criteria while using E0470 are met

Documentation Required

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

Denial Risk

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

Severe COPD criteria

Severe COPD PaCO2 criterionAwake arterial PaCO2 > 52 mmHg while breathing the member's prescribed FIO2

Severe COPD oximetry criterionSleep oximetry SpO2 < 88% for > 5 minutes (minimum recording time 2 hours) while on prescribed FIO2/oxygen

CPAP considerationCPAP must have been considered and ruled out prior to initiating BIPAP for Severe COPD

E0471 situationsE0471 may be considered when PaCO2 worsens >7 mmHg on E0470 (Situation 1) or at ≥61 days after E0470 if PaCO2 remains >52 mmHg and SpO2 <88% for >5 minutes on E0470 (Situation 2)

Restrictive thoracic / neuromuscular criteria

Required anatomic/diagnostic documentationDocumentation of neuromuscular disease or severe thoracic cage abnormality must be present

PaCO2 criterion (restrictive)Awake arterial PaCO2 > 45 mmHg measured while breathing the member's prescribed FIO2

Alternate qualifying measuresSleep oximetry SpO2 < 88% for > 5 minutes (minimum 2 hours) OR for neuromuscular disease, MIP < 60 cm H2O OR FVC < 50% predicted

Central or complex sleep apnea requirement

Required diagnostic studyPrior facility-based monitored sleep study documenting diagnosis of central sleep apnea (CSA) or complex sleep apnea (CompSA)

Therapeutic response documentationDocumented significant improvement of sleep-associated hypoventilation with the E0470 or E0471 device on the settings to be prescribed for home use

ApplicabilityCriteria apply for authorization of E0470 or E0471 for CSA/complex SA indications