Physician Documentation Requirements
- Detailed written order that contains:
- Pt.’s name
- Detailed description of the item(s) to be ordered
- Pressure settings
- Length of Need the Pt. will require the item(s)
- Physician’s printed name
- Physician’s NPI
- Physician’s signature
- Physician’s date of signature
- Face to face evaluation dated within 6 months of the detailed written order documenting the Pt.’s diagnosis of OSA or conditions and symptoms that warrant suspicion of OSA
- Medicare-covered sleep test that meets either of the following criteria:
- Apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) greater than or equal to 15 events per hour with a minimum of 30 events; OR
- AHI or RDI greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of:
- Excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; OR
- Hypertension, ischemic heart disease, or history of stroke.
- Documentation to meet all of the criteria listed above; AND
- Documentation that a single level (E0601) positive airway pressure device has been tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting.
Continued Coverage (Beyond the First Three Months of Therapy)
- Face-to-face re-evaluation by the treating physician between the 31st and 91st day after initiating therapy documenting:
- The Pt is benefiting from PAP therapy and that symptoms of obstructive sleep apnea are improved, AND
- Objective evidence of adherence to use of the PAP device reviewed by treating physician.