Medicare Compliance Requirements

Medicare has specific guidelines that must be followed to qualify for a CPAP or BiPAP and specific guidelines for that equipment to be reimbursed after the initial 3 month period. Medicare does in-force these requirements and will not reimburse for the machine or supplies if these criteria are not met.

Your Physician, the Sleep Lab and the equipment provider will work to make sure all requirements are met to ensure the initial 3 months coverage prior to you getting your equipment. Check with your company to verify they have all documentation prior to accepting your equipment.

After your set-up with your equipment you will need to make sure the compliance data and follow-up visit with your physician is met per the Medicare guidelines.

Below are the compliance requirements from Medicare for a CPAP or BiPAP to be covered after the initial 3 months

COVERAGE BEYOND THE FIRST THREE MONTHS OF
THERAPY:
Continued coverage of a CPAP or BiPAP beyond the first three months of
therapy requires that, no sooner than the 31st day but no later than the 91st day after
initiating therapy, the treating physician must conduct a clinical re-evaluation and
document that the beneficiary is benefiting from PAP therapy.
For PAP devices with initial dates of service on or after November 1, 2008, documentation
of clinical benefit is demonstrated by:
1. Face-to-face clinical re-evaluation by the treating physician with documentation
that symptoms of obstructive sleep apnea are improved; and,
2. Objective evidence of adherence to use of the PAP device reviewed by the treating
physician.LCD Information
Adherence to therapy is defined as use of PAP ≥ 4 hours per night on 70% of nights during
a consecutive thirty (30) day period anytime during the first three (3) months of initial
usage.
If the above criteria are not met, continued coverage of a PAP device and related
accessories will be denied as not medically necessary.
If the physician re-evaluation does not occur until after the 91st day but the evaluation
demonstrates that the patient is benefiting from PAP therapy as defined in criteria 1 and 2
above, continued coverage of the PAP device will commence with the date of that reevaluation.
Beneficiaries who fail the initial 12 week trial are eligible to requalify for a PAP device
but must have both:
1. Face-to-face clinical re-evaluation by the treating physician to determine the
etiology of the failure to respond to PAP therapy; and,
2. Repeat sleep test in a facility-based setting (Type 1 study).

In most cases your equipment provider will be able to download compliance data off of your CPAP/BiPAP and print a report to show adherence to your equipment per medicare requirements. Many physicians also have the ability to download your equipment for prof of compliance.

4 thoughts on “Medicare Compliance Requirements

  1. I have met the initial 3-month Medicare compliance requirement. Is there
    any other requirement I must meet to have Medicare pay for my CPAP
    machine supplies?

    • Medicare will require a face to face visit with your doctor between the 31st and 90th day. If it is past the 90th day, it is not to late, you can still make an appointment to see your doctor. Your equipment provider may have to wait until you have completed the visit to continue to bill Medicare for your equipment. If possible make the appointment before the 90th day so your equipment provider does not get a denial on the bill and then come to you. You might let them know if you are over your 90 days so they know you will be seeing your doctor for the face to face visit.

      The visit is just for your doctor to discuss the use of your machine and verify you are benefiting from the therapy. Your doctor will typically be aware of this Medicare requirement and will know the need to send documentation to your equipment provider.

  2. I can’t find the PAP Compliance information form to fill out the figures for Therapy, Blower, days, etc. I don’t know where to go on the computer – go to Apria. Com but there are so many things that appear on the page….

    • title=”Apria Compliance site”>https://cpapprod.apria.com/CPAPWebApp/

      If you follow this link it will take you to the Apria site where you are able to enter your CPAP compliance hours. The site will ask you for your name and general information then it will have you select the type of CPAP you use. After that it will lead you through where to find the hours on your machine.

      Is Apria your CPAP provider? They will also be able to complete the download for you at their office. Due to your insurance they may have to download it for you. Did they issue a modem with the CPAP? Some providers will do this for the first few months to be able to track compliance and insure you are meeting the insurance requirements.

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