Clinicians → Coverage & Documentation · Last reviewed August 17, 2026
How to Qualify a Patient for PAP Therapy
CPAP · APAP / Auto-titrating · Bi-Level (E0470) — and when it is actually Respiratory Assist (RAD / NIV / BiPAP-ST)
A plain-English guide to Medicare's PAP coverage for OSA — the AHI thresholds, the visit that must come before the sleep test, and the 31-to-91 day re-evaluation that decides whether the patient keeps the machine. Based on LCD L33718, Policy Article A52467, SDR A55426, and NCD 240.4.1.
CPAP and APAP/Auto both bill as E0601. Bi-level without backup (E0470) is PAP for OSA only after E0601 fails under optimal therapy. Bi-level with backup (E0471), ST, RAD, NIV for respiratory failure / hypoventilation / neuromuscular disease is not PAP — it lives under the Respiratory Assist Devices LCD. If the primary problem is not OSA, tell us and we will use the other pathway. This page is the OSA/PAP pathway.
For OSA PAP, Medicare needs three things at the start, then a fourth to keep it:
- In-person OSA evaluation *before* the sleep study — with neck circumference + BMI + Epworth.
- Sleep test report — AHI/RDI + total event count.
- Standard Written Order (SWO) — 6 elements + supply schedule + humidifier if wanted.
- Re-evaluation Day 31–91 with symptom improvement + adherence download (≥4 hrs/night on 70% of nights for 30 consecutive days).
Put the follow-up on the calendar before the patient leaves. Fax (800) 438-2048.
The machine is not the finish line. Coverage past month 3 requires an in-person re-evaluation no sooner than day 31 and no later than day 91 documenting both symptom improvement and objective adherence reviewed by the practitioner. Miss it and the device stops being covered — even if they use it perfectly. A late visit restarts coverage from its own date; the intervening months are lost.
Step 1 — The qualifying sleep test
The sleep test itself has to qualify
- Valid under NCD 240.4.1 and A/B MAC rules on the claim date
- FDA-approved diagnostic device
- Ordered by the treating practitioner
- Conducted by a Medicare-qualified sleep test provider complying with state rules
No aspect of a home sleep test may be performed by a DME supplier — including delivering or picking up the device.
Step 2 — The evaluation that comes first
The in-person clinical evaluation for OSA must occur before the sleep test. It is its own coverage criterion.
- Signs/symptoms: snoring, daytime sleepiness, observed apneas, choking/gasping, morning headaches
- Duration of symptoms
- Validated inventory — e.g. Epworth Sleepiness Scale
- Focused cardiopulmonary + upper airway
- Neck circumference — most omitted
- BMI — most omitted
Supplier-generated forms do not substitute for the comprehensive medical record. We can send a template to structure the note — but the note is what gets reviewed.
The office sends the home test, results come back positive, then the visit happens to review them. Every clinical instinct is correct and the claim is dead — there is no way to repair a note written after the study into an evaluation that preceded it. Schedule: see the patient, document the OSA evaluation, then order the study.
Step 3 — The Standard Written Order (SWO)
We must have a completed SWO before we bill. Six elements + PAP specifics:
- Patient name or MBI
- Order date
- Description — "CPAP device" or HCPCS or brand/model
- Quantity
- Treating practitioner name or NPI
- Practitioner signature — stamps not accepted
Also include types of supplies + approximate quantity per unit of time. Humidifier E0561 (non-heated) / E0562 (heated) if wanted. New order if quantity increases or supply type changes. We hold delivery if the signed order has not arrived — EY modifier would be a denial.
Device + humidifier + interface + supply schedule. Send the evaluation note and sleep study; we fax back an SWO ready for signature. Some items require the signed order before delivery — call (800) 977-3002 and we will tell you what must be signed before setup.
The hard part — the 31-to-91 day re-evaluation
This is where PAP patients are lost, and it has nothing to do with the sleep study.
CPAP, bi-level, and moving between them
What a switch costs in paperwork
| Scenario | New eval? | New sleep test? | Trial clock |
|---|---|---|---|
| E0601 ineffective during initial titration/home trial | No | No | Unchanged — re-evaluation day 31–91 after E0601 start, adherence on E0470 documented before day 91 |
| Same, but <30 days remain in trial | No | No | Must occur before day 120 after E0601 start |
| E0601 used >3 months, then switched | Yes | No | New 3-month trial — day 31–91 after E0470 start |
Patients who also need oxygen
Both policies must be satisfied in full. The apnea must be sufficiently treated before desaturation from a sleep study counts toward oxygen. Only a titration PSG (split-night or stand-alone) qualifies, meeting all:
| Requirement | Threshold |
|---|---|
| Titration duration | ≥2 hours |
| Apnea control | AHI/RDI ≤10/hr — or further reduction if initial <10 |
| Timing of oximetry | Only after optimal PAP settings determined while on those settings |
| Saturation | ≤88% |
Home overnight oximetry does not count — nor does oximetry from home sleep testing. Sleep-study-only qualification = stationary oxygen only, no portable. See oxygen guide → for the rest of the oxygen criteria.
Accessories and supplies
Covered when the device criteria are met; separately reimbursable at initial issue and when replaced. Recurring refills require a prospective documented patient request — no auto-ship — contact ≤30 days before supply runs out, delivery ≤10 days before, max 3-month quantity at a time.
Patients coming to us from elsewhere
Entering FFS Medicare with a machine already owned
- Sleep test before FFS enrollment meeting criteria in effect at time coverage is sought
- After enrollment: in-person evaluation documenting OSA diagnosis + continued use. No new trial or download.
Missing either item = denied.
Replacement machines
| Situation | Required |
|---|---|
| Within 5-year RUL, loss/theft/irreparable damage | No new eval / test / trial |
| After 5-year RUL | In-person eval: continues to use and benefit. No new test/trial. |
Loss/damage — expect police/insurance report.
What does not qualify
Denied as not reasonable & necessary
- AHI/RDI <5, or 5–14 without symptom/comorbidity
- Short study without enough events
- Study before in-person evaluation
- E0471 with OSA; E0470 without E0601 failure under optimal therapy
- No day 31–91 re-evaluation + adherence; supplies above maximums; refills without documented request
Non-covered (no benefit)
- Mask liners — A9270 (comfort/convenience, not interfaces)
- Monitoring smart cards/modems/transmitters — A9279 (no remote-monitoring benefit; billing as E1399 = incorrect coding)
Which equipment the patient gets
Keeping coverage in place
What happens after we deliver
- Rental → ownership: Capped rental (13 months, first 3 are the trial — day 31–91 visit is the gate to the other 10).
- KX modifier: Months 1–3 bill as covered only when initial criteria met; month 4+ only when continued-coverage criteria also met — we hold the claim and call your office if the re-eval is missing.
- Repairs during rental: Ours — no separate reimbursement.
- Hospital/SNF: Facility supplies equipment during stay — call before admission.
- Changing suppliers / MA → Medicare: First claim is new initial claim — every requirement must be met as of that date; proof of delivery even for a machine already in the bedroom.
Referral checklist
Fax to (800) 438-2048 or call (800) 977-3002
- In-person OSA evaluation before the sleep test — with symptoms + Epworth + neck circumference + BMI
- Sleep test report — AHI/RDI + total event count
- Symptom or comorbidity if AHI/RDI 5–14
- Sleep test ordered by treating practitioner, by Medicare-qualified provider
- SWO signed — no stamp; supply types + quantity per time listed
- Humidifier on order if wanted
- Follow-up scheduled Day 31–91 before the patient leaves; office knows to review + file adherence download
- For bi-level: interface fit + lower-pressure trials documented; for oxygen + PAP: titration PSG criteria met
Sources: LCD L33718 — Positive Airway Pressure Devices for the Treatment of Obstructive Sleep Apnea; Policy Article A52467; Standard Documentation Requirements A55426; NCD 240.4.1. Last reviewed August 17, 2026.
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