CPAP rental or purchase prior authorization
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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.
No material clinical or coverage changes in this revision.
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 eventsAHI or RDI > 15 events/hour AND ≥ 30 total events
ALL of the following
ANY of the following
- Documented symptoms: excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia
- Documented comorbidities: hypertension, ischemic heart disease, or history of stroke
- Member and/or caregiver received instruction from the vendor in the proper use and care of the equipment
Vendor training confirmation required on form
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
Timing exception for re-evaluation after 91 days
Special allowance for late re-evaluation:
ALL of the following
- If the treating practitioner re-evaluation occurs after day 91 but demonstrates benefit from PAP therapy per criteria for adherence and symptom improvement, continued coverage will commence with the date of that re-evaluation
Codes and Form Fields
| Form requires the provider to list HCPCS code(s) for the CPAP device/supplies requested; specific codes not enumerated on form |
| Form includes field for ICD-10 diagnosis code(s); specific codes not listed on form |
Required Documentation, Prior Authorization & Denial Risks
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
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
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.
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
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
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
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.
Policy Update Changes
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