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CPAP Authorization Requirements

November 29, 2010

This bulletin explains the information Health Care Services needs in order to review and approve CPAP machine authorizations. Please follow these guidelines: 

First Time CPAP Machine Renters:

BlueCross must approve first-time users of CPAP for 10-month rental purchase periods.

Minimal Information Required for a Clinical Review:

  • Complete scored reports of diagnostic sleep study
  • CPAP Titration study or Auto Titration study with download
  • Most current diagnostic/baseline sleep study (must have been conducted within the previous two years or the review will be referred to the medical director)   
  • History and physical, to include sleep history  

CPAP Machine Changes or Replacements:

We need a letter of medical necessity from the physician in order to upgrade or change the patient’s CPAP machine. The letter should include justification of medical necessity as well as the reason for the machine change.  Fax letters to 803-264-0258.

In some cases we approve replacement CPAPs as direct purchases. Here is the review criteria for replacement machines:                            

Minimal Criteria Required for a Replacement Review:

  • Clinical information to document history of obstructive sleep apnea diagnosis (old sleep studies are acceptable)
  • Current machine age and specific malfunction problem
Please note the patient’s current CPAP Machine should be at least 2 years old, out of warranty and have a malfunction in order to be considered for a replacement. Fax this information to 803-264-0258.
 
We have attached a checklist that completely identifies all the required documentation we need in order to complete a CPAP machine review.

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