Continuous Positive Airway Pressure or Bi-level Positive airway Pressure (CPAP/BiPAP) Supplies

Reimbursement Policy:
Continuous Positive Airway Pressure or Bi-level Positive airway Pressure (CPAP/BiPAP) Supplies

Effective Date:
January 1, 2012

Last Reviewed Date:
February 23, 2023

Purpose:
Provide guidelines for reimbursement of CPAP/BiPAP supplies to participating and non-participating professional providers.

Scope: All products are included, except

• Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
• COB

All Insured and Administrative Services Only (ASO) accounts are included. 

Definitions:

• Modifier KX – Requirements specified in the Horizon BCBSNJ medical policy for CPAP/BiPAP equipment have been met.
• Modifier EY – No physician or licensed health care provider order for this item or service.

Policy:
Many CPAP/BiPAP supplies associated with sleep therapy are designed to be disposable, including, but not limited to, masks, tubing, filters, and headgear. These items are not designed to last for extreme amounts of time.

Using the recommended replacement schedule for CPAP/BiPAP supplies from CMS/Medicare as a guideline, this policy will define when the submission of an associated CPAP/BiPAP supply is being submitted at a rate that exceeds the recommended replacement schedule and is for use with equipment that meets the criteria of Horizon BCBSNJ’s Medical Policy “Medical Management of Obstructive Sleep Apnea Syndrome”.

CPAP/BiPAP supplies may only be reimbursed when used with equipment that meets the criteria of Horizon BCBSNJ’s Medical Policy for “Medical Management of Obstructive Sleep Apnea Syndrome”.

CPAP/BiPAP supplies may only be dispensed per the order of a physician or other licensed health care professional.

Procedure:
CPAP/BiPAP supplies being dispensed for use with equipment that meets the criteria of Horizon BCBSNJ’s Medical Policy for “Medical Management of Obstructive Sleep Apnea Syndrome” AND have an order on file from a physician or licensed health care professional must be submitted with modifier KX in order to be considered for reimbursement. Claim lines containing CPAP/BiPAP supply codes submitted without modifier KX will be denied.

CPAP/BiPAP supplies related to equipment that does not meet the criteria defined in Horizon BCBSNJ’s Medical Policy for “Medical Management of Obstructive Sleep Apnea Syndrome” will be denied.

If there is no current order on file from a physician or licensed health care professional claim lines must be submitted with EY. Claim lines containing CPAP/BiPAP supply codes submitted with modifier EY, will be denied. 

CPAP/BiPAP therapy supply codes will not be reimbursed if the quantity exceeds the usual or customary frequency shown in the chart below*:

*The following sources were used as guidelines in determining the frequency of the reimbursement for the supplies associated with CPAP/BiPAP in this policy:

CMS Local Coverage Determination Policies:

• LCD11528 – NHIC, Corp.
• LCD11518 – Cigna Government Services
• LCD171 – Noridian Administrative Services
• LCD27230 – National Government Services, Inc

In denied instances where the provider is participating, there shall be no member liability.

In denied instances where the provider is non-participating, the member’s liability shall be up to the provider’s charge.

Limitations and Exclusions:

While reimbursement is considered, payment determination is subject to, but not limited to:

• Group or Individual benefit
• Provider Participation Agreement
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
• Mandated or legislative required criteria will always supersede.

History:

2/24/2013: Policy Approved

1/17/2014: Updated verbiage for messages to final approved version

3/25/2015: Revised title; added definitions for modifiers; updated into approved template

4/29/2019: Revised quantities/days for A7028, A7029, A7032, A7033, A7038 to align with CMS updates

1/27/2020: Revised quantities/days for A7031

Policy069_v5.0_02232023