Highmark Guidelines for CPAP Device Coverage are as follows (all criteria must be met):
Sleep Study Results
- Apnea-Hypopnea Index (AHI) equal to or greater than 5 (also called the Respiratory Disturbance Index (RDI), Results of CPAP Trial (at Optimum CPAP Pressure))
- AHI less than 5, or for patients with AHI greater than 20, reduction in AHI is greater than 75 percent.
- No oxygen desaturation less than 85 percent.
- Abolition of arrhythmia(s), for example, Type II second degree heart block or pause greater than 3 seconds or ventricular tachycardia at a rate greater than 140/minute lasting greater than 15 complexes.
Effective June 1, 2002, Highmark blue Cross Blue Shield HMO and POS members
must receive authorization to purchase a continuous positive airway pressure (CPAP)
device prior to treatment. For HMO and POS products, authorization for
CPAP and all other durable medical equipment items that require authorizations
must originate through the member's PCP.
To obtain authorizations for HMO members (KeystoneBlue, CommunityBlue HMO and
SecurityBlue), PCPs should contact Wright & Fillippis. For POS members (SelectBlue
and CommunityBlue POS), PCPs should obtain authorization through HMS Care
Management.
Highmark Medical Policy information is available on our online Resource Center
(www.highmarkbcbs.com)
If you have questions regarding authorization to purchase a CPAP device,
please contact Joe Mizgorski, Provider Relations representative, at
412-544-5146.
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