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*:
PROCEDURE |
PROCEDURE_DESCRIPTION |
QUANTITY |
DAYS |
A4604 |
TUBING W/INTEGRATED HEATING ELEMENT |
1 |
90 |
A7027 |
COMBINATION ORAL/NASAL MASK, EACH |
1 |
90 |
A7028 |
ORAL CUSHION FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, EACH |
6 |
90 |
A7029 |
NASAL PILLOWS FOR COMBINATION ORAL/NASAL MASK, REPLACEMENT ONLY, PAIR |
6 |
90 |
A7030 |
FULL FACE MASK, EACH |
1 |
90 |
A7031 |
FACE MASK INTERFACE, REPLACEMENT FOR FULL FACE MASK, EACH |
3 |
90 |
A7032 |
CUSHION FOR USE ON NASAL MASK INTERFACE, REPLACEMENT ONLY, EACH |
6 |
90 |
A7033 |
PILLOW FOR USE ON NASAL CANNULA TYPE INTERFACE, REPLACEMENT ONLY, PAIR |
6 |
90 |
A7034 |
NASAL INTERFACE (MASK OR CANNULA TYPE) USED W/PAP DEVICE, W/ OR W/O HEAD STRAP |
1 |
90 |
A7035 |
HEADGEAR USED W/PAP DEVICE |
1 |
180 |
A7036 |
CHINSTRAP USED W/PAP DEVICE |
1 |
180 |
A7037 |
TUBING USED W/PAP DEVICE |
1 |
90 |
A7038 |
FILTER, DISPOSABLE, USED W/PAP DEVICE |
6 |
90 |
A7039 |
FILTER, NON DISPOSABLE, USED W/ PAP DEVICE |
1 |
180 |
A7046 |
WATER CHAMBER FOR HUMIDIFIER, USED W/PAP DEVICE, REPLACEMENT, EACH |
1 |
180 |
*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