Current through Register Vol. 24-18, September 15, 2024
(1)
The medicaid agency covers, without prior authorization, one continuous
positive airway pressure (CPAP) device including related supplies, per client,
every five years. The CPAP device must have a data card and the client must
meet the following clinical criteria:
(a)The
client is diagnosed with obstructive sleep apnea (OSA) using a clinical
evaluation and a positive attended polysomnogram (PSG) performed in a sleep
laboratory or an unattended home sleep test; and
(b)For clients age twenty-one and older:
(i) The client's polysomnogram or home sleep
test demonstrates an apnea-hypopnea index (AHI) or respiratory disturbance
index (RDI) greater than or equal to fifteen events per hour ; or
(ii) The client's polysomnogram or home sleep
test demonstrates the AHI or RDI is greater than or equal to five and less than
or equal to fourteen events per hour with clinical documentation of:
(A) Excessive daytime sleepiness, impaired
cognition, mood disorders, or insomnia; or
(B) Hypertension, ischemic heart disease, or
history of stroke.
(c) For clients age twenty and younger, the
clinical criteria is considered met when there is a documented diagnosis of OSA
and polysomnography demonstrates an apnea index (AI) or AHI equal to or greater
than one and:
(i) Adenotonsillectomy has been
unsuccessful in relieving OSA; or
(ii) Adenotonsillar tissue is minimal;
or
(iii) Adenotonsillectomy is
inappropriate based on OSA being attributable to another underlying cause
(e.g., craniofacial anomaly, obesity) or adenotonsillectomy is contraindicated;
or
(iv) Family does not wish to
pursue surgical intervention.
(2) If a client meets the criteria in
subsection (1) of this section but a CPAP device has been tried and proven
ineffective, the medicaid agency will cover a bi-level respiratory assist
device (RAD) without the back-up rate. Ineffective, in this case, is defined as
documented failure to meet therapeutic goals using a CPAP during the titration
portion of a facility-based study or during home use despite optimal therapy
(i.e., proper mask selection and fitting and appropriate pressure
setting).
(3) The AHI is calculated
on the average number of events per hour. If the AHI is calculated based on
less than two hours of sleep, the total number of recorded events used to
calculate the AHI must be at least the number of events that would have been
required in a two-hour period (i.e., must reach greater than or equal to thirty
events without symptoms or greater than or equal to ten events with symptoms).
The medicaid agency pays for an initial three-month rental period for CPAP
devices.
(4)The medicaid agency
purchases a CPAP device after the three-month rental period when the following
documentation of clinical benefit is recorded in the client's file:
(a) A face-to-face clinical reevaluation of
the client by the authorized prescriber which documents that symptoms of
obstructive sleep apnea are improved; and
(b)A review of objective evidence by the
authorized prescriber of the client's adherence to use of the CPAP device.
Adherence is defined as use of the CPAP device greater than or equal to four
hours per night on seventy percent of nights during a consecutive thirty-day
period anytime during the first three months of initial usage.
(5)The medicaid agency does not
pay for a CPAP device when the client is diagnosed with upper airway resistance
syndrome (UARS).
(6) The medicaid
agency pays for the purchase of a heated humidifier for a CPAP device, once
every five years from the date the item was deemed purchased, per
client.
(7)Replacement of CPAP
device.
(a)The medicaid agency requires prior
authorization for the replacement of a CPAP device if the client has had the
device for less than five years.
(b)After five years, the client must have a
face-to-face evaluation with the treating authorized prescriber that documents
that the client continues to use and benefit from the device. The medicaid
agency does not require a new PSG (sleep test), trial period, or prior
authorization.
(c) Replacement
supplies - The medicaid agency pays for replacement supplies for a CPAP device
as follows:
(i) Full face mask, limit one
every six months;
(ii) Face mask
interface for full face mask, limit one every three months;
(iii) Nasal interface (mask or cannula type),
with or without head strap, limit one every six months;
(iv) Cushion for use on nasal mask interface,
limit one every three months;
(v)
Pillow for use on nasal cannula type interface, limit one pair every three
months;
(vi) Headgear, chin strap,
and tubing with or without integrated heating element, limit one every six
months;
(vii) Filters - Disposable,
limit two every thirty days;
(viii)
Filters - Nondisposable, limit one every six months; and
(ix) Water chamber for humidifier, limit one
every six months.
(d)Prior authorization is required if the
client does not meet the clinical criteria in this section or if the medicaid
agency has purchased a bi-level respiratory assist device for the client within
the last five years.
Statutory Authority:
RCW
41.05.021. 12-14-022, §182-552-0400,
filed 6/25/12, effective 8/1/12.
