Rule 5160-10-19 | DMEPOS: positive airway pressure devices.
(A) Definition. "Apnea-hypopnea index (AHI)" is the mean number of episodes of apnea or hypopnea per hour recorded over a period of at least two hours without the use of a positive airway pressure device, reported by polysomnogram. Extrapolation or projection of the AHI is not permitted.
(B) Coverage.
(1) The default certificate of medical necessity (CMN) form is the ODM 01903, "Certificate of Medical Necessity: Positive Airway Pressure Devices" (rev. 7/2021). The CMN includes the following information:
(a) A diagnosis of obstructive sleep apnea or other condition for which positive airway pressure is an appropriate treatment;
(b) The results of a respiratory study; and
(c) An estimated length of need.
(2) A respiratory study may be performed with a positive airway pressure device that records relevant data automatically.
(3) Payment for a positive airway pressure device may be made only if the following criteria are met:
(a) In the absence of positive airway pressure, the respiratory study yields the following results:
(i) An AHI of at least fifteen; or
(ii) An AHI of at least five coupled with documented evidence of any of the following conditions:
(a) Excessive sleepiness during waking hours;
(b) Insomnia;
(c) Mood disorder;
(d) Impaired cognition;
(e) Hypertension;
(f) Ischemic heart disease; or
(g) A history of stroke.
(b) When positive airway pressure is applied, the respiratory study yields the following results:
(i) A decrease in the number of airway obstructions per hour; and
(ii) At least one of the following indications of effectiveness:
(a) An absolute increase in oxygen saturation to at least eighty-nine per cent;
(b) A relative increase in oxygen saturation of at least fifteen per cent; or
(c) Other clinical improvement recognized by the department.
(4) A need for oxygen is established if a positive airway pressure device is effective during a respiratory study only when supplemental oxygen is administered simultaneously. That need for oxygen is presumed to last as long as the need for the positive airway pressure device, and no further respiratory study is necessary to confirm a continued need for oxygen.
(5) Payment for a variable or bilevel positive airway pressure device (i.e., a positive airway pressure device that produces different inspiratory and expiratory pressure levels) may be made only if the following criteria are met:
(a) A positive airway pressure device that produces a single pressure level has been tried and found to be ineffective; and
(b) Evidence gathered during the respiratory study or during a one-week trial period indicates that a variable or bilevel positive airway pressure device is effective.
(C) Constraint. The provider of a positive airway pressure device cannot perform the qualifying respiratory study.
Last updated July 1, 2021 at 10:54 AM
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