Positive Airway Pressure for Treatment of Obstructive Sleep Apnea

Revised: March 11, 2026

· Overview

· Eligible Providers

· TPL and Medicare

· Eligible Members

· Covered Services

· Member Compliance

· Noncovered Services

· Authorization

· Billing

Overview

Continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) devices are used for treating obstructive sleep apnea.

Eligible Providers

The following may provide positive airway pressure (PAP) devices and supplies:

· Federally qualified health centers

· Home health agencies

· Indian Health Services

· Medical suppliers

· Pharmacies

· Rural health clinics

TPL and Medicare
Providers must meet any provider criteria, including accreditation, for third party insurance or for Medicare to assist members for whom Minnesota Health Care Programs (MHCP) is not the primary payer.

MHCP quantity limits and thresholds apply to all members unless only Medicare coinsurance or deductible is requested.

Refer to the Medicare and Other Insurance section of the MHCP Provider Manual for more information.

Eligible Members

PAP devices and related supplies are covered for eligible Medical Assistance and MinnesotaCare members with a diagnosis of obstructive sleep apnea made by a physician with experience diagnosing and treating sleep apnea, using a sleep study or other appropriate diagnostic tool.

Covered Services

Codes: A4604, A7027-A7039, A7044-A7046, E0470-E0472, E0561, E0562, E0601
MHCP covers the following equipment:

· BiPAP devices without backup rate with noninvasive interface (E0470)

· BiPAP devices with backup rate with noninvasive interface (E0471)

· BiPAP devices with backup rate with invasive interface (E0472)

· CPAP devices (E0601)

· Supplies and replacement parts, including:

· Replacement parts (A7028, A7029, A7031 to A7033, A7045, A7046)

· Full face masks (A7030), nasal interfaces (A7034), oral interfaces (A7044), and combination oral and nasal masks (A7027)

· Disposable (A7038) and nondisposable (A7039) filters

· Headgear (A7035) and chinstraps (A7036)

· Tubing (A7037) and tubing with integrated heating element (A4604)

MHCP will pay for the purchase of a CPAP or BiPAP device with authorization if the member has a third party insurance that requires purchase rather than rental.

Refer to the Respiratory Equipment section of the MHCP Provider Manual for a list of disorders that qualify for coverage and for members without obstructive sleep apnea.

Included with initial dispensing:

· Compressor

· CPAP valve (if separate from mask)

· Disconnection alarm (if needed)

· Filters

· Fuses

· Instruction manual

· Manometer

Separately billable at initial dispensing:

· Head gear

· Mask

· Tubing

· Humidification device

Positive Airway Pressure Supply Codes
A4604	A7032	A7038
A7027	A7033	A7039
A7028	A7034	A7044
A7029	A7035	A7045
A7030	A7036	A7046
A7031	A7037

Refer to the Medical Supply Coverage Guide (PDF) for coverage information and limits on supplies.

Continuous Positive Airway Pressure (CPAP) Devices
The provider may dispense a CPAP device (E0601) for the first three months of the rental based on a physician’s order that includes a diagnosis of obstructive sleep apnea. During the sixth to 12th week of treatment, the supplier must verify that the member is complying with the ordered therapy. If the member has not achieved compliance by the 12th week, but has demonstrated use of the CPAP device, MHCP will continue to cover the CPAP device for an additional eight weeks. During the additional eight-week period, compliance is defined as use of CPAP four or more hours per 24-hour period for 70% of days. If the member has not achieved compliance after the additional eight weeks, the rental should end, and the provider should take the equipment back.

Bi-level Pressure Respiratory Assist (BiPAP) Devices
MHCP will pay for rental of a BiPAP device without backup rate (E0470) with authorization for members with obstructive sleep apnea when there has been a failed trial of CPAP or if there is a medical contraindication to CPAP. During the 6th to 12th week of treatment, the supplier must verify that the member is complying with the ordered therapy. If the member has not achieved compliance by the 12th week, but has demonstrated use of the BiPAP device, MHCP will continue to cover the BiPAP device for an additional eight weeks. During the additional eight-week period, compliance is defined as use of BiPAP four or more hours per 24-hour period for 70% of days. If the member has not achieved compliance after the additional eight weeks, the rental should end, and the provider should take the equipment back.

MHCP will pay for the rental of a BiPAP device with backup rate (E0471, E0472) without authorization for members with both obstructive sleep apnea and separate, coexisting breathing disorders that require ventilation assistance. The diagnoses must be billed on the claim.

Member Compliance

It must be clear that the member is using the equipment so providers can perform an accurate and valid verification of member use compliance. MHCP does not specify the method to use to verify compliance.

Keep documentation of the compliance verification in the member’s file. Recommended documentation includes the following:

· Date of verification

· Method of verification

· Name of the treating provider

· Name of the person within your organization that performed the verification

If the member is not using the equipment, the rental should end, and the provider should take the equipment back. If a member’s use of a device is not in compliance, MHCP will consider the device a noncovered service. MHCP does not cover the rental of PAP devices after the completion of the three-month trial period if the member is noncompliant. Providers may request members fill out the Advanced Recipient Notice before the trial informing the member that the device will be noncovered if they are noncompliant by the end of the trial period.

Providers must verify with the member before dispensing additional supplies that the CPAP or BiPAP device is still in use and that replacement of the supply is necessary because the existing supply is damaged or otherwise worn out.

Noncovered Services

MHCP does not cover the following:

· Rentals of devices after the third month when the member is noncompliant

· Items of convenience

Refer to information under the Noncovered Services heading in the Billing the Member (Recipient) section of the MHCP Provider Manual to review the conditions required to bill the member.

Authorization

Submit authorization requests and required documentation to the Medical Review Agent. The medical review agent will not approve requests when due to the willful or careless destruction by a member, unless documentation shows that the destruction was because of the physical or mental impairment of the member.

Authorization is always required for the following:

· Quantities over MHCP quantity limits

· Purchases of PAP devices when the primary payer requires purchase rather than rental of the device

· Rentals of BiPAP devices for treatment of obstructive sleep apnea

· Maintenance service agreements for BiPAP devices

Documentation must show a failed CPAP trial or medical contraindication to CPAP devices for rentals of BiPAP devices for obstructive sleep apnea.

Maintenance service agreements are not available for CPAP devices.

Billing

Providers are responsible to coordinate services. Refer to the Billing Policy Overview section of Provider Basics section of the MHCP Provider Manual for general billing information.

Bill PAP devices and supplies using MN–ITS 837P. Refer to the MHCP MN–ITS user guide Billing for Durable Medical Equipment, Medical Supplies, Prosthetics and Orthotics, and Augmentative Devices for claim instructions.

Refer to the following when billing for positive airway pressure devices:

· Use modifier NU for purchases.

· Use modifier RR for rentals.

· Use modifiers KH, KI, KJ, and RR as appropriate for capped rentals.

· Positive airway pressure devices are capped rental only unless a primary payer requires purchase.

· Use X12 Batch or MN–ITS 837P Professional electronic claim.

· Report the ordering provider in the Other Provider Types section of the MN–ITS interactive claim.

· If the member has Medicare, MHCP will pay the deductible or co-insurance on any units for which Medicare made payment. Any units for which Medicare denies payment must meet MHCP quantity and coverage limits.

· Bill the first three months using modifier RR and modifiers KH, KI or KJ as appropriate.

· When billing for rental after the first three months, use modifiers RR, modifiers KH, KI or KJ as appropriate and modifier KX if documentation in the file supports that the supplier has verified member compliance with treatment. Do not use modifier KX if the supplier has not verified compliance, or if the supplier has information that the member is not compliant with treatment as described under Member Compliance.

· MHCP will deny claims for rental past the first three months, unless the RR and KX modifiers are present to indicate member compliance with treatment.

· Shipping and delivery costs are included in the MHCP maximum allowable payment. Do not bill either MHCP or the member separately for these costs.

· PAP devices are expected to serve the member for at least five years. If a device is stolen or damaged beyond repair, a replacement device may be covered. Submit a claim with a Claim Attachment Criteria explaining why a replacement is required.

BiPAPs and CPAPs are capped rental items only, unless with an approved authorization for third party liability (TPL) that requires purchase rather than rental.

Supplies for PAP devices are purchase-only items.