Positive Airway Pressure (PAP) Supplies

Policy No: 127
Originally Created (Group and Individual): 03/01/2017
Originally Created (Medicare Advantage): 01/01/2017
Section: Administrative
Last Reviewed: 03/01/2024
Last Revised: 03/01/2024
Approved: 03/14/2024
Effective: 04/01/2024

This policy applies only to the supplies/accessories used with PAP devices.

Positive Airway Pressure (PAP)

A mode of respiratory ventilation used primarily in the treatment of sleep apnea.

Accessories used with PAP devices may be covered when criteria for the device are met. Our health plan utilizes Centers for Medicare & Medicaid Services (CMS) Local Coverage Determinations (LCD) to determine the reasonable and necessary maximum quantities and frequencies for PAP accessory purchases. Our health plan has, at our discretion, increased the CMS maximum quantities and/or frequencies as we deemed appropriate.

When the total units of service for a Healthcare Common Procedure Coding System (HCPCS) code have exceeded the maximum allowed within the specified time frame, our health plan will allow up to that limit and deny the remaining units. Our health plan will allow up to a 10-day grace period.

Example: Two (2) units of HCPCS A7029 are purchased on 4/1/2024. The member may receive up to four (4) additional units of HCPCS A7029 prior to 6/30/2024, for a total of six (6) units of HCPCS A7029 purchased within a 3 month/90-day period.

Billing of PAP accessories must be based on prospective, not retrospective, use. Suppliers must contact the beneficiary prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. This will be done to ensure that the items remain reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes or modifications to the order. Items delivered without a valid, documented refill request from the beneficiary will be denied as not reasonable and necessary.