CurrentDenver-Health-Medical-PlanPolicy N/A

Positive Airway Pressure (PAP) devices — Coverage Criteria

Coverage rules for initial trial, continued rental/purchase, replacements, and newly enrolled members for Positive Airway Pressure devices for Denver-Health-Medical-Plan Commercial lines of business.

Policy Summary

PayerDenver-Health-Medical-Plan

PolicyPositive Airway Pressure (PAP) devices — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProvide documentation of a prior sleep test with the initial prior authorization for members who received a device before enrollment; if unavailable, obtain a new sleep test.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3-4 monthstrial length

4 hrs/night · 70% nightscompliance

13 monthsrental to purchase

5 yearsreplacement window

Coverage Criteria for PAP Devices

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Initial trial

Compliance during trial: Usage of >=4 hours per night on 70% of nights during any consecutive 30-day period within the approved trial4 hours/night on 70% of nights
must be demonstrated to continue therapy

Second trial: A second trial within one year may be considered if the member does not reach compliance; RN discretion may allow for case-by-case consideration for unforeseen circumstances (e.g., hospitalization)within 1 year

RN discretion for exceptions

Replacement coverage

Replacement rules

Replacement within 5 years: If replaced within 5 years due to loss, theft, or irreparable damage, no new sleep test or trial is required<=5 years

Replacement after 5 years: If replaced after 5 years, a face-to-face evaluation by the treating physician within 6 months documenting continued use and benefit is required; no new sleep test or trial required>5 years and physician eval within 6 months

Coverage for members with prior devices

Newly enrolled members

Prior device documentation: If member received a device prior to enrollment and needs a new device or supplies, provide documentation of prior sleep test with initial PAR; a new sleep test is required only if prior documentation cannot be provideddocument prior sleep test

This policy does not list additional coverage exclusions beyond the specific replacement and documentation requirements described elsewhere. Coverage is determined based on the initial trial, demonstrated compliance, rental-to-purchase rules, replacement intervals, and documentation for newly enrolled members rather than by enumerating device-specific exclusions.

Coding, Usage & Rental-to-Purchase Metrics

Compliance usage

Compliance definitionUsage of the PAP device for ≥4 hours per night on 70% of nights during any consecutive 30-day period

Measurement periodAny consecutive 30-day period during the approved 3-4 month trial

PurposeDemonstrated compliance during the initial trial is required to continue therapy

Rental period to satisfy purchase

Total rental to purchase13 months total rental (includes initial trial period)

Includes trialThe 13-month rental period incorporates the 3-4 month trial

EffectSatisfies the purchase price of the PAP device after completion

Medical Necessity for Continued Rental and Purchase

Continued rental and purchase rules

Medical necessity for continued rental/purchase:

Demonstrated compliance: Member demonstrates compliance during initial 3-4 month trial as defined (>=4 hours/night on 70% of nights during any consecutive 30-day period)see compliance definition

If met, continued rental is medically necessary and rental toward purchase applies

Rental to purchase conversion: Total of 13 month rental, including trial period, required to satisfy purchase price of the device13 months

Rental & Purchase Details for PAP Devices

Equipment	Rule / Requirement	Notes
Positive Airway Pressure device	Total of 13 month rental (including initial trial) required to satisfy purchase price	Continued rental toward purchase applies only if member demonstrates compliance during the trial (see compliance definition).

Equipment	Coverage Condition	Coverage Status
Positive Airway Pressure device	Continued rental beyond the initial 3–4 month trial is medically necessary only if the member demonstrates compliance during the trial (usage ≥4 hours/night on 70% of nights during any consecutive 30-day period).	Covered

Replacement Rules and Timeframes

Replacement — within 5 years

Replacement within 5 yearsIf replaced within five (5) years for loss, theft, or irreparable damage, no new sleep test or trial is required

Applicable conditionsLoss, theft, or irreparable damage

DocumentationReplacement request does not trigger requirement for new sleep test or trial when within 5 years

Replacement — after 5 years

Replacement after 5 yearsFor replacements after five (5) years, require a face-to-face evaluation by the treating physician within six (6) months documenting continued use and benefit; no new sleep test or trial required

TimingFace-to-face evaluation must occur within six (6) months of the replacement request

PurposeDocuments that beneficiary continues to use and benefit from the device

Provider Actions and Requirements

Prior Authorization

Initial trial requirement

Initial therapy requires a three to four (3-4) month trial period. The member must demonstrate compliance within the initial trial period to continue therapy. A second trial period may be considered, within one (1) year, if the member does not reach compliance by the end of the trial period. Additional considerations for a second trial period will be made at the RN's discretion in the event of unforeseen circumstances (e.g. hospitalization, illness) and will be considered on a case-by-case basis.

Trial length: 3-4 months
Second trial: may be considered within 1 year at RN discretion

Denial Risk

Compliance requirement

Compliance is defined as usage of ≥4 hours per night on 70% of nights during any consecutive 30-day period within the approved trial. Failure to document this compliance may result in denial of continuation of therapy.

Compliance threshold: ≥4 hours/night on 70% of nights over any consecutive 30-day period

Documentation Required

Prior authorization documentation for newly enrolled members

If a member received a device prior to enrollment and requests a replacement device or supplies, the initial prior authorization request (PAR) must include documentation that the beneficiary had a qualifying sleep test. There is no requirement for a new sleep test if prior test documentation can be provided.

Provide prior sleep test documentation with initial PAR when device received before enrollment
No new sleep test required if prior documentation is available

Documentation Required

Documentation for newly enrolled members

When a newly enrolled member cannot provide documentation of a prior sleep test, a new sleep test may be required to support the PAR.

If prior test documentation is unavailable, obtain and submit a new sleep test as part of the PAR

Documentation Requirements

Documentation Required

Attach prior sleep test with initial PAR for newly enrolled members

Attach documentation of the prior sleep test to the initial PAR when the member had a PAP device before enrolling; absence of that documentation will necessitate a new sleep test.

Documentation Required

Obtain physician face-to-face evaluation for replacements >5 years

If replacing a device after five (5) years, obtain and document a face-to-face evaluation by the treating physician performed within six (6) months that confirms continued use and benefit.

Face-to-face evaluation must be within six (6) months of the replacement request
Documentation must state the member continues to use and benefit from the device

Background

Positive Airway Pressure (PAP) therapy is commonly initiated on a trial basis to establish adherence and clinical benefit. Under this policy, initial therapy requires a 3-4 month trial during which the member must demonstrate compliance (see definitions). Continued rental or purchase eligibility depends on meeting the trial and compliance thresholds and on satisfying the rental-to-purchase timeline and replacement documentation rules.

Definitions

Compliance for continued rental/purchase

Compliance threshold for continued coverageMember must demonstrate compliance (≥4 hours/night on 70% of nights during any consecutive 30-day period) during the 3-4 month trial to qualify for continued rental/purchase

Trial lengthInitial trial period of three to four (3-4) months

Rental toward purchaseIf compliance met, continued rental is medically necessary and counts toward the 13-month rental-to-purchase requirement

Not Covered

There are no explicit device-specific exclusions listed in this document. Coverage limits instead focus on timing and documentation: for example, replacements within 5 years for loss, theft, or irreparable damage do not require a new sleep test or trial, while replacements after 5 years require a treating physician’s face-to-face evaluation within 6 months documenting continued use and benefit.

Policy Summary

PayerDenver-Health-Medical-Plan

PolicyPositive Airway Pressure (PAP) devices — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProvide documentation of a prior sleep test with the initial prior authorization for members who received a device before enrollment; if unavailable, obtain a new sleep test.

SourceLink

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