Coverage Criteria for Healthcare Providers

Criteria for Coverage

Need a prescription, sleep study, chart notes, and (sometimes) a prior authorization.

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.

These criteria help ensure that the patient meets the necessary medical requirements for the prescription and use of a CPAP device, and they also provide a basis for insurance coverage. It's important for healthcare providers to adhere to these criteria to facilitate the approval process for CPAP therapy.