Does 42836 require prior authorization?

No, 42836 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 42836?

Medicare facility rate: $222.78. Non-facility rate: $222.78. Work RVU: 3.18.

Verity

`42836`

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

3.18

Facility

$222.78

Non-Facility

$222.78

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

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42836