Replacing Your Sleep Equipment
A number of variables will affect that answer, including how well you take care of your equipment as well as how often you clean it.
The following table and recommendations will help you to answer that question. This schedule has been put together by the Centers for Medicare and Medicaid Services.
|A4604 Tubing with Integrated Heat||1 per 3 months|
|A7027 Mask||1 per 3 months|
|A7028 Cushions||2 per 1 month|
|A7029 Nasal Pillows||2 per 1 month|
|A7030 Mask||1 per 3 months|
|A7031 Mask||1 per 1 month|
|A7032 Cushions||2 per 1 month|
|A7033 Nasal Pillows||2 per 1 month|
|A7034 Mask||1 per 3 months|
|A7035 Headgear||1 per 6 months|
|A7036 Chinstrap||1 per 6 months|
|A7037 Tubing||1 per 3 months|
|A7038 Disposable Filters||2 per 1 month|
|A7039 Non-disposable Filters||1 per 6 months|
|A7046 Water Chamber for Humidifier||1 per 6 months|
This section applies to PAP devices initially provided and covered while the beneficiary was in Medicare fee-for-service (FFS).
If a PAP device is replaced during the 5 year reasonable useful lifetime (RUL) because of loss, theft, or irreparable damage due to a specific incident, there is no requirement for a new clinical evaluation, sleep test, or trial period.
If a PAP device is replaced following the 5 year RUL, there must be a face-to-face evaluation by their treating physician that documents that the beneficiary continues to use and benefit from the PAP device. There is no requirement for a new sleep test or trial period.
Beneficiaries Entering Medicare
For beneficiaries who received a PAP device prior to enrollment in fee for service (FFS) Medicare and are seeking Medicare coverage of either rental of the device, a replacement PAP device and/or accessories, both of the following coverage requirements must be met:
- Sleep test – There must be documentation that the beneficiary had a sleep test, prior to FFS Medicare enrollment, that meets the Medicare AHI/RDI coverage criteria in effect at the time that the beneficiary seeks Medicare coverage of a replacement PAP device and/or accessories; and,
- Clinical Evaluation – Following enrollment in FFS Medicare, the beneficiary must have a face-to-face evaluation by their treating physician who documents in the beneficiary’s medical record that:
- The beneficiary has a diagnosis of obstructive sleep apnea; and,
- The beneficiary continues to use the PAP device.
If either criteria 1 or 2 above are not met, the claim will be denied as not reasonable and necessary.
In these situations, there is no requirement for a clinical re-evaluation or for objective documentation of adherence to use of the device.