Prior authorization: 90-day initial trial; continued coverage requires adherence or attestation

Initial coverage for CPAP/APAP (and E0470 bi-level devices for OSA) is permitted for a 90-day trial when the member meets the policy diagnostic and clinical criteria. Continued coverage beyond 90 days requires documentation of adherence during days 31–91 (objective device data or acceptable practitioner attestation for select bi-level uses). Replacement requires prescription and confirmation the device is nonfunctioning/out of warranty or >5 years old.

• Initial period: 90 days when diagnostic/clinical criteria met (adults and children per policy).
• Continued coverage requires adherence documentation between day 31 and day 91 (see adherence threshold).
• Replacement requires prescription and confirmation device is nonfunctioning/out of warranty or >5 years old.

Medicare/DSNP: Apply NCD/LCDs (CPAP 240.4; L33718; L33800)

For Medicare Advantage and DSNP members, the applicable National and Local Coverage Determinations are used to determine medical necessity: CPAP NCD 240.4, PAP Devices LCD L33718, and Respiratory Assist Devices LCD L33800. For DSNP members, if Medicare criteria do not fully approve a request, the policy guidelines on page 1 are used.

• Use NCD 240.4 for CPAP determinations.
• Use LCD L33718 for PAP devices for OSA.
• Use LCD L33800 for respiratory assist devices.
• DSNP requests default to Medicare criteria first; if not approved, revert to policy page 1 guidelines.

Attended titration & diagnostic testing: revised repeat titration and pediatric split-night; HSAT added

Attended PAP titration and repeat titration criteria were revised for clarity; pediatric split-night study criteria were updated to include re-titration in specified combinations and HSAT was added as an acceptable diagnostic test for hypoglossal nerve stimulation candidacy.

• Repeat attended titration criteria adjusted (oxygen saturation placement moved to match full-night titration and a 3rd criterion added for treatment-emergent CSA/failed split-night titration).
• Pediatric split-night (95811) criteria clarified to add 'and re-titration' for specified combinations and a new Criterion D.
• HSAT added as acceptable diagnostic test for hypoglossal nerve stimulation.

Bi-level pathway: E0470 after failed CPAP; E0471 only after E0470 ineffective with escalation criteria

Bi-level without backup (E0470) is indicated when CPAP has been tried and proven ineffective or is not tolerated as documented by a qualified health professional. E0471 (with backup rate) may be considered after an initial period of E0470 use when E0470 is ineffective or when specific escalation criteria (e.g., worsening PaCO2 or nocturnal desaturation while on E0470) are met.

• E0470 requires documentation that CPAP was tried and failed or not tolerated.
• E0471 may follow E0470 if E0470 is ineffective and physiologic/escalation criteria are satisfied (see policy criteria for PaCO2 and nocturnal desaturation thresholds).

Alternate therapies: consider only when PAP not tolerated; OTC oral appliances not covered

PAP therapy is identified as the 'gold standard' treatment for OSA; alternative non‑surgical therapies (including prescription oral appliances) may be considered only when PAP cannot be tolerated or an alternate is clinically appropriate. OTC oral appliances obtained without a prescription are not medically necessary.

• Consider alternatives only when PAP is not tolerated or contraindicated.
• Coverage for oral appliances may be subject to EPA or DME benefit terms; OTC appliances without prescription are not covered.

Requalification: face-to-face evaluation required after failed initial PAP trial

Members who fail the initial 90-day PAP trial (including due to non‑adherence) must have a face-to-face clinical re-evaluation by the treating physician before they are eligible to requalify for subsequent PAP therapy.

• Face-to-face evaluation required to determine etiology of treatment failure prior to requalification.
• Requalification is contingent on the re-evaluation findings.

Objective adherence: device download showing ≥4 hrs/night on 70% of nights (days 31–91)

For continued coverage, provide objective device download data demonstrating use ≥4 hours per night on 70% of nights during a consecutive 30‑day period anytime between day 31 and day 91 after initiation of therapy.

• Download must cover a consecutive 30‑day period within days 31–91.
• Threshold: ≥4 hours/night on 70% of nights.

Required supporting documentation: H&P, procedure note, treatment plan, and PSG/HSAT results

Submit supporting clinical documentation with requests: physician history & physical, physician procedure note, treatment plan/plan of treatment, and sleep study results (PSG or HSAT as appropriate) to support medical necessity.

• Required items: physician history & physical, physician procedure note, treatment plan, and PSG or HSAT results.
• Services beyond policy limits are subject to medical review and must be supported by documentation.

Re-evaluation required: in-person clinical assessment before requalification

A face-to-face clinical re-evaluation by the treating physician is required for members to requalify for PAP therapy after failing the initial 3‑month trial.

• Re-evaluation must be in-person and performed by the treating physician.
• Required before approving repeat coverage following initial failure (including non-adherence).

Denial risk: continued coverage denied if initial medical necessity criteria not met

Continued coverage will be denied if the initial medical necessity criteria are not met (for example, absence of qualifying diagnostic test results or failure to meet OSA diagnostic thresholds).

• If initial criteria for medical necessity are not met, continued coverage of PAP device and accessories will be denied.
• Treatment of snoring alone without OSA is not medically necessary.

Non-adherence consequence: failure to meet objective use criteria may end coverage

If objective adherence criteria during days 31–91 are not met, continued coverage of the PAP device and related supplies is considered not medically necessary and may be discontinued.

• Failure to meet the ≥4 hours/night on 70% of nights threshold on a consecutive 30‑day period within days 31–91 will render continued coverage not medically necessary.
• Coverage may be discontinued per health plan policy in cases of lack of adherence.

Documentation for medical necessity: services beyond policy require medical review

Services or supplies provided in excess of what is documented in this policy are subject to medical review; submit documentation that supports medical necessity as described in the policy.

• Medical review requires physician H&P, procedure note, treatment plan, and sleep study results (PSG or HSAT).
• Be prepared to provide documentation for replacements, upgrades, or additional services.

Denial risk: revised criteria tighten approvals and increase scrutiny

Policy revisions clarified and narrowed several criteria (for example, repeat titration language) to reduce inappropriate approvals; providers should expect increased scrutiny and denials when criteria are not met.

• Deleted broader wording that previously allowed wider approvals for repeat titration; oxygen saturation criteria were reorganized to match full‑night titration.
• Expect closer review of repeat titration and requalification requests under the revised criteria.