Continuous Positive Airway Pressure (CPAP) With or Without an In-Line Heated

Continuous Positive Airway Pressure (CPAP) With or Without an In-Line Heated Humidifier A. The Division of Medicaid defines continuous positive airway pressure (CPAP) with or without an in-line heated humidifier as a non-invasive provision of air pressure through nasal administration and a flow generator system to prevent collapse of the oropharyngeal walls during sleep. For the Division of Medicaid’s purposes, apneas and hypopneas physiologically represent the same compromise, will be considered as equivalents, and will be referred to as "respiratory events." B. The Division of Medicaid covers the rental of a CPAP during the three (3) month trial period for all beneficiaries when prior authorized by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, when the following criteria is met: 1. [Reserved], 2. When one (1) of the following is met: a) The beneficiary experiences fifteen (15) or more respiratory events per hour, or between five (5) and fourteen (14) respiratory events per hour with documentation of the following symptoms: 1) Excessive daytime sleepiness, 2) Impaired cognition, 3) Mood disorders or insomnia, or 4) Documented hypertension, ischemic heart disease, or history of stroke. b) The beneficiary is a prepubescent child and the polysomnogram demonstrates an average of one (1) or more respiratory events per hour. c) The beneficiary is a child who has documented measurements of increased end-tidal carbon dioxide (CO2) values that confirm the presence of obstructive sleep apnea. d) The beneficiary has a diagnosis of upper airway resistance syndrome with the presence of at least ten (10) respiratory related electroencephalogram (EEG) arousals per hour of sleep accompanied by a history of clinically significant daytime sleepiness or documented excessive daytime sleepiness as determined by a Multiple Sleep Latency Test, with a significant reduction in EEG arousals following administration of CPAP. C. The Division of Medicaid will review, for determination of coverage for a CPAP, with appropriate documentation, the following medical conditions: 1. Persistent hypoxemia of oxygen saturation (SaO2) less than ninety percent (90%) during sleep even in the absence of obstructive sleep apnea, 2. Central sleep apnea, 3. Chronic alveolar hypoventilation syndrome, 4. Intrinsic lung disease, 5. Neuromuscular disease. D. After the initial three (3) month trial period, the CPAP may be recertified up to seven (7) additional months with a CPAP Compliance Certificate of Medical Necessity completed by the ordering physician. 1. If the equipment was not effective or, if the beneficiary was non-compliant, the equipment must be returned to the vendor. 2. The rental fees paid for the three (3) month trial period will apply toward the maximum reimbursement for purchase. 3. After ten (10) consecutive months of rental, including the trial period, the CPAP is owned by the beneficiary. E. The Division of Medicaid reimburses the DME supplier for the supplies listed below: 1. Full face mask used with a positive airway pressure device, 2. Face mask interface, replacement for full face mask, 3. Replacement pillows for nasal application device, 4. Replacement cushion for nasal mask interface, 5. Nasal interface, either a mask or cannula type, used with positive airway pressure device with or without head strip, 6. Headgear used with positive airway pressure device, 7. Chin strap used with positive airway pressure device, 8. Tubing used with positive airway pressure device, 9. Disposable Filter, used with positive airway pressure device, 10. Non-Disposable Filter, used with positive airway pressure device, 11. Oral interface used with positive airway pressure device, 12. Combination oral/nasal CPAP mask, 13. Replacement oral cushion for oral/nasal mask, 14. Replacement nasal pillows for oral/nasal mask, and 15. Humidifier water chamber. F. Division of Medicaid does not cover for more than the usual maximum replacement amount unless documentation is submitted that justifies a larger quantity in the individual case.