Loading...Loading...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
Policy Applies to: Group and Individual & Medicare Advantage
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.
HCPCS Code | Code Description | Maximum Units | Frequency |
|---|---|---|---|
A4604 | Tubing with integrated heating element for use with positive airway pressure device | 1 | 3 months/90 days |
A7027 | Combination oral/nasal mask, used with continuous positive airway pressure device, each | 1 | 3 months/90 days |
A7028 | Oral cushion for combination oral/nasal mask, replacement only, each | 6 | 3 months/90 days |
A7029 | Nasal pillows for combination oral/nasal mask, replacement only, pair | 6 | 3 months/90 days |
A7030 | Full face mask used with positive airway pressure device, each | 1 | 3 months/90 days |
A7031 | Face mask interface, replacement for full face mask, each | 3 | 3 months/90 days |
A7032 | Cushion for use on nasal mask interface, replacement only, each | 6 | 3 months/90 days |
A7033 | Pillow for use on nasal cannula type interface, replacement only, pair | 6 | 3 months/90 days |
A7034 | Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap | 1 | 3 months/90 days |
A7035 | Headgear used with positive airway pressure device | 1 | 6 months/180 days |
A7036 | Chinstrap used with positive airway pressure device | 1 | 6 months/180 days |
A7037 | Tubing used with positive airway pressure device | 1 | 3 months/90 days |
A7038 | Filter, disposable, used with positive airway pressure device | 6 | 3 months/90 days |
A7039 | Filter, non-disposable, used with positive airway pressure device | 1 | 6 months/180 days |
A7046 | Water chamber for humidifier, used with positive airway pressure device, replacement, each | 1 | 6 months/180 days |
Centers for Medicare & Medicaid Services (CMS) Local Coverage Determination (LCD), L33718, Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea
Centers for Medicare & Medicaid Services (CMS) Local Coverage Determination (LCD), L33800, Respiratory Assist Devices
None
Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.