Harvard Pilgrim HealthCare
Medical Policy

Positive Airway Pressure Devices for Sleep Apnea

Subject: Positive Airway Pressure Devices for Sleep Apnea

Background:
Positive airway pressure is a treatment for obstructive sleep apnea, as well as other uses in the critical care setting. Continuous positive airway pressure (CPAP) delivers a constant stream of air that holds the user’s airway open. Auto-titrating positive airway pressure (APAP) automatically titrates, or calibrates, the power of its stream based on user breath resistance to deliver the minimum pressure needed to keep the airway open. Bilevel positive airway pressure (BiPAP) alternates between two pressure levels to provide a lower pressure against user exhalations, with some models relying on a breath sensor and others also having a “backup” rate on a timer to switch the pressure when no breath change is detected. Adaptive servo-ventilation positive airway pressure (ASV-PAP) increases the pressure of its stream when it detects signs of central OSA.

Authorization:

Prior authorization is required for positive airway pressure devices requested for members enrolled in commercial (HMO, POS, and PPO) products.

This policy utilizes InterQual® criteria and/or tools, which Harvard Pilgrim may have customized.

You may request authorization and complete the automated authorization questionnaire via HPHConnect at www.harvardpilgrim.org/providerportal. In some cases, clinical documentation and/or color photographs may be required to complete a medical necessity review. Please submit required documentation as follows:

• Clinical notes/written documentation —via HPHConnect Clinical Upload or secure fax (800-232-0816)
• Photographs— HPHConnect Clinical Upload function, email (utilization_requests@harvardpilgrim.org), or mail (Utilization Management, 1600 Crown Colony Dr., Quincy, MA 02169). Please note that photographs should not be faxed as faxed photos cannot be utilized in making a medical necessity determination.

Providers may view and print the medical necessity criteria and questionnaire via HPHConnect for providers (Select Resources and the InterQual® link) or contact the commercial Provider Service Center at 800-708-4414. (To register for HPHConnect, follow the instructions here.) Members may access these materials by logging into their online account (visit www.harvardpilgrim.org, click on Member Login, then Plan Details, Prior Authorization for Care, and the link to clinical criteria) or by calling Member Services at 888-333-4742.

Policy and Coverage Criteria:

For this policy, Harvard Pilgrim Health Care (HPHC) draws upon the following InterQual® criteria:

• Adaptive Servo-Ventilation Positive Airway Pressure Device (Version 2023)
• Auto-titrating Positive Airway Pressure (APAP) Device (Version 2023)
• Continuous Positive Airway Pressure (CPAP) Device (Version 2023)
• Respiratory Assist Device, Bi-Level Pressure Capability, w/Backup Rate Feature, Used w/Noninvasive Interface (Version 2023)
• Respiratory Assist Device, Bi-Level Pressure Capability, w/o Backup Rate Feature, Used w/Noninvasive Interface (Version 2023)

Positive Airway Pressure (PAP) Devices for Sleep Apnea

HPHC policies are based on medical science, and written to apply to the majority of people with a given condition. Individual members’ unique clinical circumstances, and capabilities of the local delivery system are considered when making individual UM determinations.

Coverage described in this policy is standard under most HPHC plans. Specific benefits may vary by product and/or employer group. Please reference appropriate member materials (e.g. Benefit Handbook, Certificate of Coverage) for member-specific benefit information.