Continuous Positive Airway Pressure (CPAP) and Auto-Adjusting Positive Airway Pressure (APAP) Devices
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Defines medical necessity criteria and coverage rules for Continuous Positive Airway Pressure (CPAP) and Auto-Adjusting Positive Airway Pressure (APAP) devices for adults and children with obstructive sleep apnea, including initial 90-day trials and continuation requirements.
BiPAP and non-invasive ventilator criteria and associated codes were removed and placed into the new medical policy #1.01.57 for Home Non-Invasive Positive Pressure Ventilation (NIPPV).
Policy edit with duplicative criteria removed while policy intent remained unchanged.
Added medically necessary criteria for initial CPAP device requests when the individual has documented AHI or RDI greater than a threshold (text truncated in this excerpt).
Summary of changes tracking was implemented.
Coverage Criteria for CPAP / APAP Devices
Adult indications (Initial Therapy)
Covered when ANY one of the following is met:
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Pediatric indications (Initial Therapy)
Covered when ANY one of the following pediatric-specific conditions is met (90-day continuation review not required for pediatric members):
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Continuation of coverage after 90-day trial
Continuation is covered when BOTH of the following are demonstrated:
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Repair of medically necessary CPAP (out of warranty)
Repair is considered medically appropriate when ALL of the following are met:
chunks 20-24
Replacement of medically necessary CPAP (out of warranty)
Replacement is considered medically appropriate when ALL of the following are met:
chunks 27-30
Device selection and alternatives
Covered when appropriate for management of OSA and intolerance to first-line therapy:
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Short-term replacement/monitoring billing
Operational coverage rules:
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Guideline-based coverage criteria
Covered when following guideline-based conditions are met or when device is indicated per referenced clinical guidance
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Initial Therapy
Covered when ALL of the following are met (excerpted references):
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Requests for continuous positive airway pressure (CPAP) that are intended solely to treat snoring without documented obstructive sleep apnea (OSA) are considered not medically necessary. Coverage requires objective evidence of OSA (see policy thresholds for required AHI/RDI documentation).
Repair or replacement claims for CPAP equipment that was damaged or lost due to patient neglect, theft, or abuse are ineligible for coverage. Likewise, if another available coverage source exists (for example, homeowners, rental, auto, or liability insurance), repair or replacement should be pursued through that source and is not covered under this policy.
Replacement of a properly functioning CPAP device, its components, or accessories is not medically necessary. This exclusion includes replacements sought for reasons of upgraded technology or improved aesthetics rather than clinical need; routine or elective swaps of functioning equipment will not be covered.
Accessories or components that the peer‑reviewed literature has deemed not medically necessary or investigational are excluded from coverage. The Health Plan will apply the same determinations when assessing coverage for CPAP-related accessories and components.
Devices marketed to clean or sanitize CPAP equipment (for example, SoClean and similar products) are classified as convenience items and are ineligible for coverage. Claims for such cleaning/sanitizing devices will be denied under this policy.
Coverage under this medical policy is dependent on the member's product. If a given product does not cover a service, the medical policy criteria do not apply and the service is considered excluded for that product. Providers should verify contract-specific coverage before submitting requests.
Criteria and billing codes for bilevel positive airway pressure (BiPAP) and other non‑invasive ventilators have been removed from this CPAP/APAP policy and relocated to Medical Policy 1.01.57 (Home Non‑Invasive Positive Pressure Ventilation). Requests for these devices should be evaluated under that policy.
Use of CPAP for isolated snoring in the absence of documented obstructive sleep apnea is explicitly listed as not medically necessary. Providers should document diagnostic testing demonstrating OSA when seeking coverage for positive airway pressure therapy.
CPAP is considered not medically necessary for treatment of snoring when there is no accompanying diagnosis of obstructive sleep apnea (OSA). Coverage requires objective sleep testing (PSG or HST) demonstrating OSA per policy thresholds.
Procedure and supply codes in the policy may be annotated as Experimental/Investigational (E/I) or Not Medically Necessary (NMN) where applicable. Specific code‑level determinations are provided in the policy's coding sections and should be referenced when submitting claims.
Any request for BiPAP or other non‑invasive ventilator devices submitted under this CPAP/APAP policy may be considered not applicable and should instead be assessed under Medical Policy 1.01.57. Providers should redirect prior authorization requests and coding inquiries for these devices to that related policy.
Coding and Billing Codes
| No codes listed |
| A9279 | Monitoring feature/device, stand-alone or integrated, any type, including all accessories, components, and electronics, not otherwise classified |
| 94660 | Continuous positive airway pressure ventilation (CPAP), initiation and management |
| A7027-A7039 | Accessories/supplies, code range for positive pressure airway devices (code range) |
| A7044-A7046 | Accessories/supplies, code range for positive pressure airway devices (code range) |
| A9279 | Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components and electronics, not otherwise classified |
| E0561 | Humidifier, nonheated, used with positive airway pressure device |
| E0562 | Humidifier, heated, used with positive airway pressure device |
| E0601 | Continuous airway pressure (CPAP) device |
| E66.2 | Morbid (severe) obesity with alveolar hypoventilation |
| G47.00 | Insomnia, unspecified |
| G47.10 | Hypersomnia, unspecified |
| G47.20 | Circadian rhythm sleep disorder, unspecified type |
| G47.8 | Other sleep disorders |
| G47.9 | Sleep disorder, unspecified |
| I50.9 | Heart failure, unspecified |
| J39.8 | Other specified diseases of upper respiratory tract |
| J44.1 | Chronic obstructive pulmonary disease with (acute) exacerbation |
| J44.9 | Chronic obstructive pulmonary disease, unspecified |
| No codes listed |
Provider Requirements, Documentation, and Billing Guidance
90-day trial; continuation requires improvement + compliance
Initial therapy is a 90-day trial. Continuation beyond the 90-day trial requires both documented improvement in AHI and symptoms during the trial and demonstrated compliance (e.g., device use ≥70% of nights for ≥4 hours per night during a consecutive 30-day period).
Document device compliance for replacement/continuation
Proof of compliance with positive pressure device use must be documented when seeking replacement or continuation after the initial trial, referencing the same compliance definition used for continuation (70% of nights for ≥4 hours/night over 30 consecutive days).
Monitoring (A9279) inclusive; one-month rental if out-of-warranty
The monitoring feature/device (HCPCS A9279) is considered inclusive to the positive airway pressure device and is not separately reimbursable; when a CPAP malfunctions and is out of warranty (not due to manufacturer recall), coverage is allowed for a one-month rental while the device is repaired.
- HCPCS A9279 is inclusive to the PAP device and not separately billable.
- One-month rental allowed for malfunctioning, out-of-warranty CPAP during repair (recall exclusions apply).
PA for initial CPAP requests: include sleep study showing AHI/RDI above threshold
Initial CPAP requests require prior authorization and must include documentation of a sleep study (PSG or HST) showing a documented AHI or RDI greater than the policy threshold, plus relevant clinical information as described in the policy.
Pediatric pathway: CPAP/APAP when surgery fails, contraindicated, or not preferred
For children <18 years, CPAP/APAP is appropriate when adenotonsillectomy has failed to relieve OSA symptoms, surgery is contraindicated, or a nonsurgical approach is strongly preferred; note that a 90-day continuation review is not required for pediatric members.
- Failure of adenotonsillectomy to relieve symptoms.
- Contraindication to surgical intervention.
- Strong preference for nonsurgical approach.
If intolerant of fixed CPAP pressure, try expiratory relief CPAP or APAP
If a patient cannot tolerate constant high CPAP pressure, consider CPAP with expiratory relief or APAP as alternate options before discontinuing positive pressure therapy.
- CPAP with expiratory relief (e.g., C-Flex) or APAP may improve tolerance.
Use APAP or CPAP with expiratory relief if fixed-level CPAP not tolerated
APAP or CPAP with expiratory relief may be used as alternatives when a patient does not tolerate standard fixed-level CPAP.
Offer fixed-level CPAP first for symptomatic mild OSA; APAP if intolerant
Guideline-preferred initial therapy: offer fixed-level CPAP for individuals with mild OSA whose symptoms affect quality of life and who have not improved with lifestyle changes; APAP may be offered as an alternative if CPAP is not tolerated.
- Fixed-level CPAP recommended for symptomatic mild OSA after unsuccessful lifestyle measures.
- APAP as alternative when CPAP intolerance occurs.
Include sleep study results and symptom/comorbidity documentation
Documentation must include polysomnography (PSG) or home sleep testing (HST) results showing the AHI or RDI used to establish medical appropriateness, along with related symptoms or comorbid conditions.
- Include PSG/HST report with AHI or RDI values.
- Document associated symptoms (e.g., daytime sleepiness) or comorbid cardiovascular disease when applicable.
Include pediatric end-tidal CO2 or sleep study data when applicable
For pediatric members when hypercarbia is relevant, include end-tidal CO2 measurements or sleep study documentation (e.g., end-tidal CO2 >53 mm Hg or >50 mm Hg for 10–24% of sleep time) as applicable to support medical necessity.
Documentation required for repair: DME date, warranty, compliance, function, repair expectation
For repair authorization, physician documentation must include the date of DME initiation, manufacturer warranty information if applicable, attestation that the patient has been compliant and continues to benefit, description that the DME is no longer functioning adequately and interferes with activities of daily living, and that repair is expected to restore full function per manufacturer definition.
Monitoring inclusive; short-term rental allowed if device out of warranty
Monitoring features/devices (HCPCS A9279) are considered inclusive to the PAP device and not separately billable; when a CPAP malfunctions and is out of warranty (not due to manufacturer recall), coverage is allowed for a one-month rental while the device is repaired.
Provide PAP education, mask fitting, demonstration before titration
Before titration, candidates should receive PAP education, hands-on demonstration, careful mask fitting, and acclimatization as part of pre-titration preparation per AASM guidance.
Include documented AHI or RDI > policy threshold for initial CPAP requests
Initial CPAP device requests must include documentation of a documented AHI or RDI greater than the policy threshold; ensure the sleep study report is attached to the request (exact numeric threshold referenced in policy materials).
CPAP for isolated snoring may be denied (not medically necessary)
Requests for CPAP solely to treat snoring without documented obstructive sleep apnea are considered not medically necessary and may be denied.
Damage/loss exclusions: neglect, theft, abuse, or alternate coverage
Repair or replacement claims are ineligible if the equipment was damaged or lost due to patient neglect, theft, abuse, or when another available coverage source (e.g., homeowners or auto insurance) exists.
Cleaning/sanitizing devices (e.g., SoClean) not covered
Devices used to clean or sanitize CPAP devices (for example, SoClean) are considered convenience items and are ineligible for coverage; claims for such devices may be denied.
Policy applicability is contract dependent — check member product coverage
Coverage and applicability of this policy are contract dependent; if a product does not cover a service, medical policy criteria do not apply which may lead to denial based on the member’s product.
BiPAP/NIPPV device requests moved to policy 1.01.57
Requests for BiPAP and other non-invasive ventilators and associated codes have been moved to policy 1.01.57; such requests may be redirected or denied under this policy and should be submitted under policy 1.01.57.
Background and Clinical Context
Obstructive sleep apnea (OSA) is diagnosed by polysomnography (PSG) or home sleep testing (HST) using the apnea–hypopnea index (AHI) or respiratory disturbance index (RDI). These indices are used to determine medical necessity for CPAP/APAP initiation and continuation; documentation of AHI/RDI and clinical symptoms or comorbid conditions is required per the coverage criteria.
Definitions and Key Terms
Policy Revision and Approval History
Policy committee approved the policy on 06/18/26 (listed as the most recent committee approval).
Policy committee approved the policy on 07/17/25 (prior committee approval entry).
Off-cycle review added medically necessary criteria for initial CPAP requests when the individual has a documented AHI or RDI greater than a specified threshold.
Policy committee approved the policy on 01/23/25 (committee approval entry).
Policy committee approved the policy on 01/18/24 (committee approval entry).
Policy committee approved the policy on 01/19/23 (committee approval entry).
Policy committee approved the policy on 03/24/22 (committee approval entry).
Policy committee approved the policy on 07/15/21 (committee approval entry).
Policy committee approved the policy on 06/25/20 (committee approval entry).
Policy committee approved the policy on 06/27/19 (committee approval entry).
Policy committee approved the policy on 04/26/18 (committee approval entry).
Policy committee approved the policy on 04/27/17 (committee approval entry).
Policy committee approved the policy on 08/25/17 (committee approval entry).
Committee approval period listed from 04/25/13 through 04/28/16 (grouped approval entries in source).
Policy committee approved the policy on 04/26/12 (committee approval entry).
Policy committee approved the policy on 04/28/11 (committee approval entry).
Policy committee approved the policy on 02/26/09 (committee approval entry).
Policy committee approved the policy on 06/26/08 (committee approval entry).
Policy committee approved the policy on 04/26/07 (committee approval entry).
Policy committee approved the policy on 03/16/06 (committee approval entry).
Policy committee approved the policy on 04/21/05 (committee approval entry).
Policy committee approved the policy on 01/20/05 (committee approval entry).
Policy committee approved the policy on 12/18/03 (committee approval entry).
Policy committee approved the policy on 02/20/03 (committee approval entry).
Policy committee approved the policy on 01/17/02 (committee approval entry).
Policy committee approved the policy on 10/18/01 (committee approval entry).
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