Recently, questions have been received by the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) medical directors regarding the requirements in the Positive Airway Pressure (PAP) local coverage determination (LCD) for documentation of ineffective therapy while on an E0601 device, according to information from CMS contractor, NHIC.

To clarify when a patient may switch from an E0601 to an E0470 device, the following language will replace the current verbiage in the documentation requirements section in an upcoming revision of the PAP LCD. The change will be effective for dates of service on or after August 1, 2010.

For beneficiaries changing from an E0601 to E0470 due to ineffective therapy while on E0601 (either during a facility-based titration or in the home setting), the treating physician must document that both of the following issues were addressed prior to changing to an E0470 device:

A. Interface fit and comfort. An appropriate interface has been properly fit and the beneficiary is using it without difficulty. This properly fit interface will be used with the E0470 device; and
B. E0601 pressure settings. The current pressure setting of the E0601 prevents the beneficiary from tolerating the therapy and lower pressure settings of the E0601 were tried but failed to:

1. Adequately control the symptoms of OSA; or
2. Improve sleep quality; or
3. Reduce the AHI/RDI to acceptable levels.

For additional coverage, coding, and documentation requirements, suppliers should refer to the PAP LCD and related Policy Article on the DME MAC Web sites.