National Coverage Determination (NCD)

Continuous Positive Airway Pressure (CPAP)


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Tracking Information

Publication Number
Manual Section Number
Manual Section Title
Continuous Positive Airway Pressure (CPAP)
Version Number
Effective Date of this Version
Ending Effective Date of this Version
Implementation Date
Implementation QR Modifier Date

Description Information

Benefit Category
Durable Medical Equipment

Please Note: This may not be an exhaustive list of all applicable Medicare benefit categories for this item or service.

Item/Service Description

CPAP is a non-invasive technique for providing single levels of air pressure from a flow generator, via a nose mask, through the nares. The purpose is to prevent the collapse of the oropharyngeal walls and the obstruction of airflow during sleep, which occurs in obstructive sleep apnea (OSA).

Indications and Limitations of Coverage

The diagnosis of OSA requires documentation of at least 30 episodes of apnea, each lasting a minimum of 10 seconds, during 6-7 hours of recorded sleep. The use of CPAP is covered under Medicare when used in adult patients with moderate or severe OSA for whom surgery is a likely alternative to CPAP.

Initial claims must be supported by medical documentation (separate documentation where electronic billing is used), such as a prescription written by the patient's attending physician, that specifies:

  • A diagnosis of moderate or severe obstructive sleep apnea, and
  • Surgery is a likely alternative.
  • The claim must also certify that the documentation supporting a diagnosis of OSA (described above) is available.

The use of CPAP devices are covered under Medicare when ordered and prescribed by the licensed treating physician to be used in adult patients with OSA if either of the following criteria using the Apnea-Hyopopnea Index (AHI) are met:

  • AHI ≥ 15 events per hour, or

  • AHI ≥ 5 and ≤ 14 events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease or history of stroke.

The AHI is equal to the average number of episodes of apnea and hyponea per hour and must be based on a mimimum of 2 hours of sleep recorded by polysomnography using actual recorded hours of sleep (i.e., the AHI may not be extrapolated or projected).

Apnea is defined as a cessation of airflow for at least 10 seconds. Hypopnea is defined as an abnormal respiratory event lasting at least 10 seconds with at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline, and with at least a 4% oxygen desaturation.

The polysomnography must be performed in a facility - based sleep study laboratory, and not in the home or in a mobile facility.

Initial claims for CPAP devices must be supported by information contained in the medical record indicating that the patient meets Medicare's stated coverage criteria.

Cross Reference
Claims Processing Instructions

Transmittal Information

Transmittal Number
Revision History

12/2001 - Expand coverage for use in obstructive sleep apnea.  Effective and implementation dates 04/01/2002. (TN 150) (CR 1949)

06/1987 - Revised indications for treatment to include patients for whom surgery is a likely alternative to CPAP, and deleted documentation requirements. Effective date 01/12/1987. (TN 15)

12/1986 - Provided coverage when used in adult patients with moderate or severe obstructive sleep apnea who have failed to obtain relief from other non-invasive therapies. Effective date 01/12/1987. (TN 12)


National Coverage Analyses (NCAs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with NCAs, from the National Coverage Analyses database.

Coding Analyses for Labs (CALs)

This NCD has been or is currently being reviewed under the National Coverage Determination process. The following are existing associations with CALs, from the Coding Analyses for Labs database.

Additional Information

Other Versions
Title Version Effective Between
Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) 3 03/13/2008 - N/A View
Continuous Positive Airway Pressure (CPAP) Therapy For Obstructive Sleep Apnea (OSA) 2 04/04/2005 - 03/13/2008 View
Continuous Positive Airway Pressure (CPAP) 1 04/01/2002 - 04/04/2005 You are here
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Reasons for Denial
Note: This section has not been negotiated by the Negotiated RuleMaking Committee. It includes CMS’s interpretation of it’s longstanding policies and is included for informational purposes. Tests for screening purposes that are performed in the absense of signs, symptoms, complaints, or personal history of disease or injury are not covered except as explicity authorized by statue. These include exams required by insurance companies, business establishments, government agencies, or other third parties. Tests that are not reasonable and necessary for the diagnosis or treatment of an illness or injury are not covered according to the statue. Failure to provide documentation of the medical necessity of tests may result in denial of claims. The documentation may include notes documenting relevant signs, symptoms, or abnormal findings that substantiate the medical necessity for ordering the tests. In addition, failure to provide independent verification that the test was ordered by the treating physician (or qualified nonphysician practitioner) through documentation in the physician’s office may result in denial. A claim for a test for which there is a national coverage or local medical review policy will be denied as not reasonable and necessary if it is submitted without an ICD-9-CM code or narrative diagnosis listed as covered in the policy unless other medical documentation justifying the necessity is submitted with the claim. If a national or local policy identifies a frequency expectation, a claim for a test that exceeds that expectation may be denied as not reasonable and necessary, unless it is submitted with documentation justifying increased frequency. Tests that are not ordered by a treating physician or other qualified treating nonphysician practitioner acting within the scope of their license and in compliance with Medicare requirements will be denied as not reasonable and necessary. Failure of the laboratory performing the test to have the appropriate Clinical Laboratory Improvement Act of 1988 (CLIA) certificate for the testing performed will result in denial of claims.