A7049, Expiratory positive airway pressure intranasal resistance valve
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Document scoring definitions used: apnea = cessation of airflow ≥10 seconds; hypopnea = ≥10-second event with ≥30% reduction in thoracoabdominal movement or airflow and ≥4% oxygen desaturation.
- Provider must document beneficiary education on proper CPAP use prior to device use; documentation may note a caregiver if they will consistently operate the device.
- Sleep testing used to establish the diagnosis must be ordered by the treating physician and furnished under appropriate physician supervision; this ordering and supervision should be documented.
- Document the AHI or RDI as the average number of events per hour; if based on <2 hours of continuous recorded sleep, document that the total recorded events meet the minimum required for a 2-hour period.
Key Coverage Criteria
- Removable oral appliances are proven and medically necessary for treating obstructive sleep apnea (OSA) when a sleep study confirms diagnosis and prior evaluation has occurred.
- APAP titration is medically necessary for adults with clinically significant OSA when: (1) AHI/RDI/REI ≥15/hour; or (2) AHI/RDI/REI ≥5/hour with signs/symptoms such as daytime sleepiness or cardiovascular risk; or (3) significant weight change or symptom change suggesting CPAP retitration or discontinuation.
- CPAP is covered for adult patients with obstructive sleep apnea (OSA).
- Positive diagnosis for CPAP coverage must include clinical evaluation and a positive attended PSG or unattended home sleep test using a Type II or Type III home sleep monitoring device.
- Positive diagnosis for CPAP coverage may be established by an unattended Type IV home sleep test that measures at least 3 channels.
- Initial 12-week CPAP coverage is allowed if AHI or RDI ≥ 15 events/hour, or AHI or RDI 5–14 events/hour with documented symptoms (excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia) or documented hypertension, ischemic heart disease, or history of stroke.
7 Active Policies
UHC-POL-obstructive-sleep-apnea-treatment, Obstructive and Central Sleep Apnea Treatment
BCBSIL-MED204.006, Medical Management of Sleep Related Breathing Disorders
BCBSMT-MED204.006, Medical Management of Sleep Related Breathing Disorders
BCBSNM-MED204.006, Medical Management of Sleep Related Breathing Disorders
BCBSOK-MED204.006, Medical Management of Sleep Related Breathing Disorders
Related Codes
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