CPAP Prepayment Review Set in Jurisdiction B

SYRACUSE, N.Y. — Sleep therapy providers in Jurisdiction B
beware: National Government Services, the Jurisdiction B DME MAC,
announced Jan. 20 it will implement a widespread prepayment review
of claims for CPAP devices (HCPCS E0601).

Letters will be sent to providers requesting documentation that
must be returned to the DME MAC within 30 days of the letter’s date
or the claim will be denied as not medically necessary, according
to NGS.

In its notice, NGS said requested documentation would
include:

• A detailed written order, signed and dated by the treating
  physician, for the CPAP device and any other accessory billed on
  the same claim;

• Medical records documenting a face-to-face clinical evaluation
  by the treating physician, prior to the sleep test, to assess the
  patient for obstructive sleep apnea. This report would commonly
  include pertinent information about the signs and symptoms of the
  sleep disorder, duration of symptoms, cardiopulmonary and upper
  airway exam, neck circumference, and body mass index (BMI);

• The report of a Medicare-covered sleep test. If the test is a
  home sleep test, rather than a facility-based polysomnogram, it
  should include information concerning the credentials of the
  physician interpreting the test, as indicated in the Positive
  Airway Pressure (PAP) Devices local coverage determination
  (LCD);

• Documentation that the patient and/or caregiver has received
  instruction in the proper use and care of the equipment from the
  supplier of the CPAP device;

• If the claim is for the fourth or subsequent rental month,
  medical record documentation of a clinical re-evaluation by the
  treating physician, between the 31st and 91st day of therapy with
  the PAP device, showing that symptoms of obstructive sleep apnea
  are improved;

• If the claim is for the fourth or subsequent month,
  documentation verifying that the patient used the device for four
  or more hours on 70 percent of the nights during a 30-consecutive
  day period during the first three months of initial PAP usage;
  and

• Proof of delivery of the item(s) delivered to the
  beneficiary.

Read the full notice on the NGS Web site.