CurrentBlue Cross Blue Shield - North CarolinaPolicy N/A

CPAP rental or purchase prior authorization

Prior authorization request form and clinical criteria for initial 3-month rental and for purchase after rental of continuous positive airway pressure (CPAP) devices for members of Blue Cross Blue Shield - North Carolina.

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyCPAP rental or purchase prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit the completed CPAP Rental or Purchase Prior Authorization Request Form with required HCPCS and ICD-10 codes and supporting clinical documentation to avoid delays.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-monthInitial rental period

4h/70%Compliance threshold for purchase after rental

AHI/RDI criteriaDiagnostic thresholds for initiating PAP

Medical Necessity Criteria for CPAP Rental and Purchase

Initial 3-month rental - Medical necessity for initiating CPAP rental

Initial 3-month rental is approvable when ALL of the following are satisfied:

ALL of the following

HCPCS code(s) for the requested item are provided on the form
HCPCS code field is required on the PA form
There was a face-to-face in-person clinical evaluation by the treating physician to assess for obstructive sleep apnea prior to the sleep test
Yes/No on form
One of the following sleep test diagnostic criteria is met
- Apnea Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) is > 15 events per hour with a minimum of 30 events

Policy Summary

PayerBlue Cross Blue Shield - North Carolina

PolicyCPAP rental or purchase prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionSubmit the completed CPAP Rental or Purchase Prior Authorization Request Form with required HCPCS and ICD-10 codes and supporting clinical documentation to avoid delays.

SourceLink

On This Page

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Purchase after completion of 3-month rental

Purchase after completing a 3-month rental is approvable when ALL of the following are satisfied:

ALL of the following

Member used the device at least 4 hours per night on 70% of nights over a 30-day period≥4 hours/night on ≥21 of 30 days (compliance chip or sleep record required)
In-person clinical re-evaluation by the treating practitioner documenting improvement in obstructive sleep apnea symptoms
Re-evaluation must be in-person and documented
Treating practitioner reviewed objective evidence of adherence to PAP use
Compliance download or device data reviewed and documented

Non-compliance and extension or requalification

Options if member fails compliance or initial trial:

ANY of the following

- Provider documents specific extenuating circumstances (e.g., hospitalization, illness, mask or machine fit issues)
- Provider documents education provided to member on importance of compliance
ALL of the following
- In-person clinical re-evaluation by treating practitioner to determine etiology of failure to respond to PAP therapy
- Repeat sleep test in a facility-based setting (Type 1 study) — may be repeat diagnostic, titration, or split-night study

Required Documentation, Prior Authorization & Denial Risks

Prior Authorization

Submit completed PA form with required fields

Submit the completed CPAP Rental or Purchase Prior Authorization Request Form with HCPCS and ICD-10 codes and required clinical answers; incomplete forms may delay processing.

HCPCS code(s) (REQUIRED) field must be completed on the form
ICD-10 Code(s) field must be provided

Documentation Required

Provide sleep test and clinical evaluation documentation

Document a face-to-face, in-person clinical evaluation by the treating physician prior to the sleep test and attach sleep test results demonstrating the required AHI/RDI thresholds; if neither threshold is met, submit relevant medical records for review.

AHI or RDI > 15 events/hour with a minimum of 30 total events
AHI or RDI > 5 and < 15 events/hour with a minimum of 10 events plus documented symptoms or specified comorbidities
If criteria a or b are not met, submit a copy of the member's relevant medical records for review

Documentation Required

Provide vendor instruction confirmation

Confirm on the PA form that the member and/or caregiver received instruction from the vendor on the proper use and care of the CPAP equipment.

Documentation Required

Provide objective adherence data for purchase requests

For requests to purchase after the 3-month rental, submit an objective compliance download or device record showing use of the device at least 4 hours per night on 70% of nights over a 30-day period and document an in-person clinical re-evaluation showing improvement in OSA symptoms.

Compliance requirement: ≥4 hours/night on ≥21 of 30 days (via compliance chip or sleep record)
Treating practitioner must have reviewed objective evidence of adherence and documented symptom improvement during in-person re-evaluation

Documentation Required

Document extenuating circumstances for non-compliance

If requesting one additional month of rental due to non-compliance, document specific extenuating circumstances that prevented compliance and that the member received education on the importance of compliance.

Examples of extenuating circumstances: hospitalization, illness, issues with fit of mask or machine function
Document that the member has been educated on the importance of compliance

Denial Risk

Risk of denial if criteria not met

Requests that do not include required diagnostic thresholds, documentation of in-person evaluations, vendor training confirmation, or objective adherence evidence may be denied; Blue Cross NC may request medical records to verify the information.

Numeric Thresholds and Defined Terms

Key thresholds for CPAP rental and purchase

Diagnostic AHI/RDI threshold (severe)AHI or RDI > 15 events/hour with minimum 30 events

Diagnostic AHI/RDI threshold (mild-moderate with symptoms/comorbidity)AHI or RDI > 5 and < 15 events/hour with minimum 10 events plus documented symptoms or specified comorbidities

Compliance for purchase≥4 hours/night on ≥70% of nights over 30 days (≥21 of 30 days)

Definitions

AHIApnea Hypopnea Index — number of apneas and hypopneas per hour of sleep.

RDIRespiratory Disturbance Index — includes apneas, hypopneas, and respiratory event-related arousals per hour.

Type 1 studyFacility-based polysomnography performed in-lab (referenced on form as required for repeat testing when re-qualifying).

Clinical and Administrative Context

This form operationalizes prior authorization requirements for rental and purchase of continuous positive airway pressure (CPAP) devices. It requires the ordering provider to supply the requested HCPCS code(s) and relevant ICD-10 diagnosis codes, document a face-to-face in-person clinical evaluation prior to the sleep test, and confirm vendor instruction to the member or caregiver. Initial approval for a 3-month rental is contingent on meeting diagnostic thresholds: either AHI or RDI > 15 events/hour with at least 30 total events, or AHI or RDI > 5 and < 15 events/hour with at least 10 total events plus documented qualifying symptoms or specified comorbidities. If those thresholds are not met, the form instructs providers to submit relevant medical records for review.

Transition from rental to purchase requires objective adherence data and clinical reassessment: the member must have used the device an average of ≥4 hours per night on ≥70% of nights over a 30-day period (≥21 of 30 days) as shown by a compliance chip or sleep record, and the treating practitioner must perform an in-person re-evaluation documenting symptomatic improvement and review of adherence data. For members who fail the initial 12-week trial, requalification requires both an in-person re-evaluation to determine cause of failure and a repeat facility-based (Type 1) sleep study; the form also allows consideration of one additional month of rental when the provider documents extenuating circumstances and education provided to the member. A late re-evaluation after day 91 that documents benefit may result in continued coverage effective the date of that re-evaluation.

OpenPayer

CPAP rental or purchase prior authorization

Medical Necessity Criteria for CPAP Rental and Purchase

Codes and Form Fields

Required Documentation, Prior Authorization & Denial Risks

Numeric Thresholds and Defined Terms

Clinical and Administrative Context

Policy Update Changes