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May 2015

We’re clarifying our CPAP policy regarding replacement units

We’re providing a clarification of our CPAP policy as it relates to members receiving a replacement unit. This clarification pertains to CPAP replacement devices provided from Oct. 1, 2011, to the present for the following situations:

  • Following the five-year reasonable useful lifetime
  • During the five-year reasonable useful lifetime if a replacement is required and the warranty on the device has expired

 Provider guidelines when dispensing and billing a replacement CPAP are as follows:

  • A new prescription is required for the replacement CPAP.
  • Durable medical equipment providers must document in the patient’s record that they have confirmed it is a replacement.
  • Replacement units must be submitted as a rental only and will be considered purchased only after 10 consecutive rental months.
  • DME providers must bill the KX modifier on all confirmed CPAP replacement claims as well as the supplies and accessories used with them.

It’s important to note that a new sleep test or trial period isn’t required for the replacement CPAP. Providers are still required to document compliance for members who don’t qualify for a replacement CPAP as directed in our policy.

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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2014 American Medical Association. All rights reserved.
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