42831
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
2.74
Facility
$212.76
Non-Facility
$212.76
Documentation Required
- For BIPAP/related devices coverage for nocturnal hypoventilation/restrictive thoracic disorders: documentation of qualifying diagnosis codes (G47.34, G47.36, G70.*, J40-J44, M95.4, Q67.8) and clinical documentation that CPAP is intolerant or ineffective
- General implication: sleep study results (in-lab polysomnography or appropriately conducted home sleep test meeting device channel requirements) and relevant clinical notes documenting symptoms, prior CPAP trial/intolerance, and comorbid conditions/tests (blood pressure, Epworth, MSLT) are required as part of selection criteria (these specific documentation elements are referenced in the policy text)
- For CPAP and PAP device/accessory claims: documentation of device prescription, indication (diagnosis and AHI/comorbidity/symptom documentation as required), and any documentation of prior trials/education or reasons for intolerance where alternative devices are requested.
Key Coverage Criteria
- Continuous Positive Airway Pressure (CPAP) devices and accessories — HCPCS E0601 and listed masks/interfaces/accessories (A7027–A7046, A7037–A7039, E0561–E0562, etc.) covered for obstructive sleep apnea (G47.33) when selection criteria are met (AHI thresholds specified).
- CPAP coverage with AHI ≥15 for OSA (G47.33) — CPAP is covered when selection criteria (AHI ≥15) are met.
- CPAP coverage with AHI 5–14 for OSA when specified comorbid conditions (see list above) or excessive sleepiness criteria are present — CPAP covered when selection criteria met.
- AutoPAP/APAP and pressure-relief technologies (e.g., C-Flex) — covered under applicable HCPCS when selection criteria for CPAP/APAP are met.
- Bi-level PAP and respiratory assist devices (E0470, E0472) — covered for OSA members intolerant of CPAP or when CPAP/AutoPAP is ineffective; covered for diagnoses with nocturnal hypoventilation (G47.34, G47.36) and for restrictive thoracic and chronic lower respiratory disease diagnoses (G70.*, J40–J44, M95.4, Q67.8) when selection criteria are met.
- Testing for OSA is considered medically necessary for individuals who present with clinical features suggestive of moderate to severe OSA as evidenced by: 1) Excessive daytime sleepiness (EDS) and ONE of the following are present: a) BMI greater than 30; or b) Excessive sleepiness while driving; or c) Loud/intense snoring; 2) Epworth Sleepiness Scale (ESS) score of 10 or greater; or 3) Witnessed nocturnal apnea, choking and/or gasping.
2 Active Policies
AETNA-CPB-0004 — Obstructive Sleep Apnea in Adults
ANTHEM-CG-SURG-36 — CG-SURG-36 Adenoidectomy
Related Codes
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