Description
Continuous positive airway pressure machines (CPAPs) billed without the diagnosis of obstructive sleep apnea (OSA) will be denied.
Affected Code(s)
E0601
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1833(e) - Payment of Benefits
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1834(a)(7)(C)(i), (ii) and (iii)- Replacement of Items
3. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1842(p)(4)- Provisions Relating to the Administration of Part B
4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, §1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
5. 42 Code of Federal Regulations (CFR), §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.929- Post-Payment Review
7. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
8. 42 CFR §405.986- Good Cause for Reopening
9. 42 CFR §410.38- Durable medical equipment, prosthetics, orthotics and supplies (DMEPOS): Scope and conditions
10. 42 CFR §414.210(f)- Payment for Replacement of Equipment
11. Medicare Claims Processing Manual, Ch. 20- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) §50- Payment for Replacement of Equipment; §110- General Billing Requirements - for DME, Prosthetics, Orthotic Devices, and Supplies
12. Medicare Benefit Policy Manual, Ch. 16- General Exclusions from Coverage, §180- Services Related to and Required as a Result of Services Which Are Not Covered Under Medicare
13. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
14. Medicare National Coverage Determinations Manual: Chapter 1, Part 4 (Sections 200 – 310.1) Coverage Determinations; Section 240.4 - Continuous Positive Airway Pressure (CPAP) Therapy for Obstructive Sleep Apnea (OSA); Effective March 13, 2008
15. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Determination L33718: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea, Effective 10/01/2015; Revised 09/27/2021
16. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Policy Article A52467: Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea- Policy Article; Effective 10/01/2015; Revised 8/8/2021
17. CGS Administrators, LLC, and Noridian Healthcare Solutions, LLC, Local Coverage Article: Standard Documentation Requirements for All Claims Submitted to DME MACs A55426 - Effective 01/01/2017; Revised 01/01/2023
18. HCPCS Level II Codebook