Coverage Criteria for Healthcare Providers

Prescription / Standing Written Order

Must include:

• Diagnosis: Must include a diagnosis (e.g., Obstructive Sleep Apnea – G47.33).
• Length of Need: Indicate the duration for which the CPAP is required.
• Quantity: Specify the quantity of CPAP prescribed.
• Date: Include the date of the prescription.
• Signature: Must be signed by the prescribing healthcare provider.

Note: A template from Kohll's Rx may be faxed over to ensure all necessary information is provided.

Sleep Study

• Initial Device: Sleep study must be less than a year old.
• Replacement Device: No restriction on the age of the sleep study.
• AHI (Apnea Hypopnea Index) and RDI(Respiratory Disturbance Index) Criteria:
  • AHI and RDI less than 5: Patient doesn’t qualify for CPAP.
  • AHI or RDI greater than 4 and less than 15:
    • Qualifies if chart notes mention a secondary diagnosis (e.g., excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease, or history of stroke).
  • AHI or RDI of 15 or greater: Patient qualifies without a secondary diagnosis.

Chart Notes

• Must be less than a year old.
• Initial Device: Chart notes must be from before the sleep study, with a note indicating that a “sleep study has been ordered.”
• Replacement Device: Chart notes must mention the patient is continuing to use and benefit from their CPAP.