CurrentCareSource GeorgiaPolicy MP-MM-1323

Positive Airway Pressure Devices for Pulmonary Disorders Continued Rental

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This policy governs CareSource medical-necessity determinations and continued rental authorization for CPAP and BiPAP positive airway pressure devices. It applies to providers requesting rental coverage for eligible members in Georgia, Ohio, and West Virginia Marketplace plans.

Policy Summary

PayerCareSource Georgia

PolicyPositive Airway Pressure Devices for Pulmonary Disorders Continued Rental

Policy CodePolicy MP-MM-1323

Change TypeRevised

Effective DateOctober 1, 2026

Last ReviewOct 1, 2026

Next Review DateN/A

Key ActionSubmit adherence documentation with annual prior authorization requests for BiPAP E0471 and E0472.

SourceLink

POLICY UPDATE CHANGES

Rental-period medical-necessity requirements for PAP devices were revised.

4PAP device HCPCS codes addressed

4+ hours/night, 70% of nightsAdherence threshold

30 daysAdherence assessment period

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CurrentCareSource GeorgiaPolicy MP-MM-1323

Positive Airway Pressure Devices for Pulmonary Disorders Continued Rental

Customize your policy alerts

Sign up for CareSource Georgia Policy MP-MM-1323 alerts

Get alerted when Policy MP-MM-1323 changes without checking for updates manually.

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Policy Summary

PayerCareSource Georgia

PolicyPositive Airway Pressure Devices for Pulmonary Disorders Continued Rental

Policy CodePolicy MP-MM-1323

Change TypeRevised

Effective DateOctober 1, 2026

Last ReviewOct 1, 2026

Next Review DateN/A

Key ActionSubmit adherence documentation with annual prior authorization requests for BiPAP E0471 and E0472.

SourceLink

POLICY UPDATE CHANGES

Rental-period medical-necessity requirements for PAP devices were revised.

4PAP device HCPCS codes addressed

4+ hours/night, 70% of nightsAdherence threshold

30 daysAdherence assessment period

Rental Coverage Criteria

Initial Rental — E0601 and E0470

During the first 3 months of rental, E0601 and E0470 are medically necessary when the applicable MCG Health clinical criteria are met.

The applicable MCG Health clinical criteria are met for the requested PAP device.

Continued Rental — E0601 and E0470

During months 4–13 of rental, E0601 and E0470 are medically necessary when adherence documentation is submitted.

Documentation confirming adherence is submitted.

Adherence is use of the PAP device as prescribed by the ordering physician: utilization for 4 or more hours per night for 70% of the nights during the most recent consecutive 30-day period during the first initial usage.

Initial Rental — E0471 and E0472

During the first 6 months of rental, E0471 and E0472 are medically necessary when the applicable MCG Health clinical criteria are met.

The applicable MCG Health clinical criteria are met for the requested PAP device.

Continued Rental — E0471 and E0472

During months 7–12 of rental, E0471 and E0472 are medically necessary when adherence documentation is submitted.

Documentation confirming adherence is submitted.

Annual Authorization — E0471 and E0472

For annual authorization of E0471 and E0472, CareSource considers the device medically necessary when ALL of the following are met and documentation is submitted with the prior authorization request.

ALL of the following

The applicable MCG Health clinical criteria are met for the requested PAP device.
Documentation confirming adherence is submitted.
Adherence is use of the PAP device as prescribed by the ordering physician: utilization for 4 or more hours per night for 70% of the nights during the most recent consecutive 30-day period during the first initial usage. Documentation must be submitted annually with the prior authorization request.

Covered PAP Device Codes

Covered HCPCS CodesHCPCSCovered

E0601	CPAP, continuous pressure capability, used with noninvasive nasal or face mask.
E0470	BiPAP, Bi-level pressure capability, without backup rate feature, used with noninvasive nasal or face mask.
E0471	BiPAP, Bi-level pressure capability, with backup rate feature, used with noninvasive nasal or face mask.
E0472	BiPAP, Bi-level pressure capability, with backup rate feature, used with invasive tracheostomy tube.

PAP adherence threshold

Minimum use4 or more hours per night

Required frequency70% of nights

Assessment periodThe most recent consecutive 30-day period during initial usage

Provider Submission Requirements

Prior Authorization

Annual Authorization Required for E0471 and E0472

Submit a prior authorization request annually for continued rental of BiPAP devices E0471 and E0472. Include documentation confirming adherence and supporting that the applicable MCG Health clinical criteria continue to be met.

E0471 — BiPAP with backup rate feature for use with a noninvasive nasal or face mask.
E0472 — BiPAP with backup rate feature for use with an invasive tracheostomy tube.
Annual prior authorization is required for continued rental; submit the request with adherence documentation.

Documentation Required

Adherence Documentation Required

Document adherence to the PAP device as prescribed by the ordering physician and submit the documentation with the annual prior authorization request for E0471 and E0472. CareSource defines adherence as use for 4 or more hours per night on 70% of the nights during the most recent consecutive 30-day period during the first initial usage.

Positive Airway Pressure Therapy

Positive airway pressure (PAP) devices use a machine with a mask or other apparatus fitted over the nose and/or mouth to provide pressure that keeps the airways open. CPAP delivers a single continuous pressure and is used for sleep-related breathing disorders, including sleep apnea; BiPAP delivers separate positive pressure during inhalation and exhalation and may be used for pulmonary disorders such as chronic obstructive pulmonary disease. PAP devices may also be used for preterm infants with underdeveloped lungs. Devices should be used as prescribed by the physician during sleep, including at home, while traveling, and during naps.

Key Terms

Adherence

Prescribed useUse of the PAP device as prescribed by the ordering physician

Utilization threshold4 or more hours per night for 70% of nights

Measurement periodThe most recent consecutive 30-day period during initial usage

Bi-Level Positive Airway Pressure (BiPAP) Device

Device typeBi-Level Positive Airway Pressure (BiPAP) device

Pressure deliveryUses mild bilevel, or two levels of air pressure

PurposeKeeps airways open

Medical Necessity Requirements

Medical Necessity: E0601 and E0470

For CPAP E0601 and BiPAP E0470, medical necessity is assessed by rental period:

Rental-period requirements: During the first 3 months of rental, MCG Health clinical criteria must be met. During months 4–13, documentation confirming adherence must be submitted.First 3 months: MCG Health clinical criteria; months 4–13: adherence documentation

Adherence means use for 4 or more hours per night on 70% of nights during the most recent consecutive 30-day period during initial usage.

Medical Necessity: E0471 and E0472

For BiPAP E0471 and E0472, medical necessity is assessed by rental period and annual authorization:

Rental-period requirements: During the first 6 months of rental, MCG Health clinical criteria must be met. During months 7–12, documentation confirming adherence must be submitted. Annual prior authorization requests require both MCG Health clinical criteria and adherence documentation.

Rental and Purchase Rules

Device(s)	Rental period	Medical necessity requirement
E0601 CPAP; E0470 BiPAP without backup rate	Months 1–3	MCG Health clinical criteria must be met.
E0601 CPAP; E0470 BiPAP without backup rate	Months 4–13	Documentation confirming adherence must be submitted. Adherence is use for 4 or more hours per night on 70% of nights during the most recent consecutive 30-day period during initial usage.

Device(s)	Rental period	Medical necessity requirement
E0471 BiPAP with backup rate for use with a noninvasive nasal or face mask; E0472 BiPAP with backup rate for use with an invasive tracheostomy tube	Months 1–6	MCG Health clinical criteria must be met.
E0471 BiPAP with backup rate for use with a noninvasive nasal or face mask; E0472 BiPAP with backup rate for use with an invasive tracheostomy tube	Months 7–12	Documentation confirming adherence must be submitted. Adherence is use for 4 or more hours per night on 70% of nights during the most recent consecutive 30-day period during initial usage.
E0471 BiPAP with backup rate for use with a noninvasive nasal or face mask; E0472 BiPAP with backup rate for use with an invasive tracheostomy tube	Annually thereafter	Submit documentation confirming adherence annually with the prior authorization request. Both the MCG Health clinical criteria and adherence documentation must be met.

Required Adherence Documentation

Documentation Required

Submit required adherence documentation

Submit adherence documentation demonstrating use for 4 or more hours per night on 70% of nights during the most recent consecutive 30-day period during initial usage. Documentation confirming adherence is required for the applicable continued-rental period; for E0471 and E0472, submit it annually with the prior authorization request.

E0601 and E0470: submit adherence documentation for months 4-13 of rental.
E0471 and E0472: submit adherence documentation for months 7-12 and annually with the prior authorization request.