CurrentCareSourcePolicy PASSE-MM-1586

Positive Airway Pressure Devices for Pulmonary Disorders Continued Rental-AR PASSE-MM-1586, MEDICAL POLICY STATEMENT Arkansas PASSE

Defines medical necessity, rental-to-purchase terms, adherence requirements, applicable HCPCS device codes, modifiers, and supply/billing instructions for CPAP and BiPAP devices for Arkansas PASSE members.

Policy Summary

PayerCareSource

PolicyPositive Airway Pressure Devices for Pulmonary Disorders Continued Rental-AR PASSE-MM-1586, MEDICAL POLICY STATEMENT Arkansas PASSE

Policy CodePolicy PASSE-MM-1586

Change TypePeriodic review; added supplies section

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionProviders must document that the MCG Health clinical criteria are met for the requested CPAP/BiPAP device when submitting initial rental or continued rental reviews.

SourceLink

POLICY UPDATE CHANGES

Periodic review completed 07/02/2025 and D. VI (Supplies) was added.

4HCPCS codes referenced

15Max rental months referenced

>=4 hrs/70%Adherence threshold

1Unlisted DME invoice required

Coverage Summary

Quick facts

HCPCS codes referencedE0601, E0470, E0471, E0472

Maximum rental months referenced15 months (rent-to-purchase for CPAP E0601 and BiPAP E0470)

Unlisted DME code invoice requirementA9999 requires manufacturer’s invoice attached to the claim form

Adherence threshold>= 4 hours per night for 70% of nights during the most recent consecutive 30-day period

Medical-Necessity Criteria and Rental Month Rules

Medical necessity for PAP devices (general)

CareSource uses MCG Health clinical criteria; rental medical necessity varies by device type and rental month:

MCG criteria required: MCG Health clinical criteria for the requested device (CPAP E0601 or BiPAP E0470/E0471/E0472) are met

Rental month-specific medical necessity — CPAP (E0601) and BiPAP (E0470)

Coverage for E0601 and E0470 during rental months:

rental-month-criteria

months1-3
- mcg_requirement: MCG Health clinical criteria are met for initial rental
months4-15: For rental months 4-15: device is medically necessary when documentation confirming adherence is submitted
Adherence defined as use >= 4 hours per night for 70% of nights during the most recent consecutive 30-day period

Rental month-specific medical necessity — BiPAP with backup features (E0471, E0472)

Coverage for E0471 and E0472 during rental months:

bipap-backup-rental

months1-6
- mcg_requirement_bk: MCG Health clinical criteria are met for initial rental
months7-12: For rental months 7-12: device is medically necessary when documentation confirming adherence is submitted
Adherence = use >= 4 hours/night on >=70% of nights in the most recent consecutive 30-day period
annual_adherence_submission: Documentation confirming adherence must be submitted annually with the medical necessity review request
When submitted annually, adherence documentation will be reviewed along with MCG Health clinical criteria

General documentation requirement

For continued rental and medical necessity review:

general-documentation: Both documentation confirming adherence (when required by rental month criteria) and MCG Health clinical criteria must be met for continued rental reviews

Adherence defined as utilization for 4 or more hours per night for 70% of the nights during the most recent consecutive 30-day period

Codes and Status

CPAP deviceHCPCSCovered

E0601

CPAP, continuous pressure capability, used with noninvasive nasal or face mask

BiPAP / Bi-level devicesHCPCSCovered

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

Unlisted DME supply or accessoryHCPCS

A9999

Unlisted Durable Medical Equipment. Manufacturer's invoice must be attached to the claim form; misc DME supply or accessory; not otherwise specified

Provider Actions & Billing Rules

Documentation Required

Submit MCG Health clinical criteria documentation

Providers must document that the MCG Health clinical criteria are met for the requested CPAP/BiPAP device when submitting initial rental or continued rental reviews.

E0601
E0470
E0471
E0472

Documentation Required

Submit adherence documentation for continued rental

For specified rental months (CPAP/BiPAP), submit documentation confirming adherence (use ≥4 hours/night on ≥70% of nights during most recent consecutive 30-day period). Documentation must be submitted annually with medical necessity review requests where required.

E0601
E0470
E0471
E0472
Note: Annual submission required where specified by rental-month criteria

Billing Rule

Rental billing and modifiers

Report 1 unit = rental with RR modifier per day. For E0601, use RR and NU modifiers or no modifiers as recommended. For E0470, E0471, E0472, use RR plus EP for beneficiaries under 21 and NU for beneficiaries aged 21 and over.

1 unit = rental with RR modifier per day
E0601: RR and NU modifiers or no modifiers
E0470/E0471/E0472: RR + EP for beneficiaries under 21; NU for beneficiaries 21 and over

Billing Rule

A9999 invoice requirement

When submitting A9999, attach the manufacturer's invoice to the claim form and submit A9999 without modifier.

A9999 (Unlisted DME): attach manufacturer’s invoice
Submit A9999 with no modifier

Background and Evidence

Positive airway pressure (PAP) devices, including CPAP and BiPAP, use a machine with a mask or other apparatus to provide positive pressure and keep airways open. CPAP treats sleep-related breathing disorders such as sleep apnea and may be used in preterm infants with underdeveloped lungs; BiPAP treats lung disorders like COPD by delivering two levels of pressure. PAP devices can improve sleep quality, reduce snoring, and lessen daytime sleepiness. These devices should be used according to the physician's order and used regularly—every time during sleep at home, while traveling, and during naps—to achieve effective outcomes. Adherence is defined as use for >= 4 hours per night for 70% of nights during the most recent consecutive 30-day period.

Source	Reference
MCG Health references	MCG Health ACG guidelines A-0994 (BiPAP) and A-0431 (CPAP), 28th ed., updated March 14, 2024
CMS LCD	LCD L33718 Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea, updated January 1, 2024

Definitions

AdherenceUse of the PAP device as prescribed defined as utilization for 4 or more hours per night for 70% of the nights during the most recent consecutive 30-day period during the initial usage period.

E0601CPAP, continuous pressure capability, used with noninvasive nasal or face mask

E0470BiPAP, Bi-level pressure capability, without backup rate feature, used with noninvasive nasal or face mask

E0471BiPAP, Bi-level pressure capability, with backup rate feature, used with noninvasive nasal or face mask

E0472BiPAP, Bi-level pressure capability, with backup rate feature, used with invasive tracheostomy tube

Effective Date	Name	Number	Type
2024-01-01	Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea	L33718	LCD