Insurance Coverage for Bi-Level PAP (Bi-PAP)
Date Published
Quick answer: most insurance plans, including Medicare, cover BiPAP (bi-level positive airway pressure) when there is documented medical necessity beyond standard CPAP. The most common qualifying criteria: (1) documented failure of CPAP therapy at adequate pressure (typically a trial with persistent intolerance or inadequate AHI reduction), (2) pressure requirements above 15 cm H2O where CPAP becomes uncomfortable, (3) central sleep apnea or complex sleep apnea diagnosed on titration, (4) hypoventilation syndromes including obesity hypoventilation and COPD overlap (CMS LCD L33718 for BiPAP coverage criteria, and L33800 for non-invasive ventilation in respiratory failure). Coverage requires a sleep study showing the relevant clinical findings and a physician order specifying BiPAP. The 90-day adherence requirement (4 hours / 70 percent of nights) still applies for continued coverage, same as CPAP.
PAP (positive airway pressure) therapy treats obstructive sleep apnea by delivering pressurized air into the airways to keep it open during the night while sleeping. PAP can reduce or completely eliminate sleep apnea (learn more about how PAP therapy works here).
There is significant evidence that treating sleep apnea with PAP therapy may improve quality of life, reduce daytime sleepiness, reduce motor-vehicle accidents, improve hypertension and even reduce death due to cardiovascular events.
The most common device, making up perhaps 85% of new devices, is an auto-CPAP or APAP. These modern devices adjust the pressure needed by the patient automatically. Auto-CPAPs utilize dynamic software algorithms to adjust pressure breath-by-breath based on real-time upper airway resistance. The pressure needed by a patient may change based on body position, sleep stage, alcohol use and many other factors. Fixed pressure CPAPs, that deliver a constant level of pressure, account for about 10% of new devices, often as a replacement for an existing fixed-pressure device. A third type of device is called bi-level PAP or BiPAP accounts for about 5% of new devices. BiPAPs can be more comfortable for some patients. Learn more about how that device works and what's required to get approval from your insurance company.
How is a treating PAP pressure determined?
The industry-wide shift toward home sleep testing has established auto-CPAP devices as the standard first-line therapeutic selection for new orders. Auto-CPAPs use an algorithm to determine the pressure needed by the patient for each breath, so no titration study is needed to determine a fixed pressure.
For fixed-pressure CPAP devices, the pressure needed is usually determined during a titration sleep study, a type of polysomnography that is performed in a sleep center. The patient is hooked up to electrodes to measure his or her sleep and wears a PAP mask to sleep (learn more about the different types of sleep studies here). Once the patient is asleep, the sleep technician will monitor the sleep, track apneas and adjust the pressure that is being delivered. Typically, as the pressure is increased, apneas will decrease. The goal of the titration study is to find the lowest pressure that will eliminate all or most of the breathing events. The technician may increase and later decrease the pressure. Once the data is scored and reviewed by a physician, a treating CPAP pressure can be determined.
Some patients with severe sleep apnea (learn more about the differences between mild, moderate and severe sleep apnea here) will need higher air pressure to keep the airway open. If the pressure gets very high the patient may be uncomfortable. In some cases, a two-level PAP device, called a bi-level or BiPAP device can be used.
How does bi-level PAP work?
Bi-level PAP delivers two different pressures of air: a higher pressure when the patient breathes in and a lower pressure when she breathes out. This lower pressure reduces the resistance and relieves the abdominal muscles, both of which can make the patient more comfortable.
The patient will also be titrated on this device to find the treating pressure that reduce or eliminate all events. The maximum inspiratory (breathing in) pressure on bi-level shouldn't exceed 30 cm H20 and difference between the inspiratory (breathing in) and expiratory (breathing out) pressures should not be less than 4 cm H20.
In general, a patient could be transitioned from CPAP to Bi-level when the CPAP pressure approaches 15 cm H2O. Exhaling against this CPAP pressure can be uncomfortable for many patients.
Aside from discomfort from PAP pressure, there is another subset of patients that may benefit from the use of bi-level therapy to time their breathing during night.
Why aren't all patients put on bi-level PAP?
Bi-level PAP is usually reserved for patients requiring higher pressures because auto-CPAP is sufficient for most patients with lower pressure requirements.
Additionally, because the bi-level machine is more sophisticated, it is more expensive than auto-CPAP. In Southern California, Medicare reimburses around $500 for auto-CPAP and $1,300 for a BiPAP machine device without backup (learn more about how insurance companies pay for PAP therapy here). Insurance companies require proof that the patient attempted CPAP therapy before they will cover the more expensive bi-level machine.
Even though bi-level is more comfortable for some patients, recent studies have not shown that it leads to better adherence to therapy over auto-CPAP.
When will insurance cover bi-level PAP?
Insurance companies will usually cover Bi-PAP if the patient has a diagnosis of obstructive sleep apnea and has shown "intolerance" using CPAP therapy. The patient may have been previously dispensed a CPAP device or may have merely attempted CPAP therapy during an in-center titration and was uncomfortable due to increasing pressure approaching or exceeding 15 cm H2O.
Medicare has clearly defined coverage criteria for sleep studies and PAP devices. Many commercial and HMO insurance plans follow Medicare guidelines. We have outlined their guidelines for bi-level PAP below:
Medicare will cover a bi-level respiratory assist device without backup (this is what they call a bi-level or BiPAP) for patients with obstructive sleep apnea if the patient meets the criteria for PAP therapy:
- AHI or RDI > 15 events per hour with a minimum of 30 events or
- AHI or RDI > 5 to14 events per hour with a minimum of 10 events recorded and documentation of:Excessive daytime sleepiness, impaired cognition, mood disorders or insomnia; or
- Hypertension, ischemic heart disease or history of stroke
and:
- CPAP is tried and proven ineffective based on therapeutic trial conducted in either a facility (sleep center) or home setting.
- A face-to-face clinical re-evaluation is completed during the 3-month trial period. The physician must document that the following issues were addressed prior to changing from CPAP:Mask fit and comfort (read more about different types of mask and how they fit here)
- CPAP pressure setting prevent tolerating therapy and lower settings were tried, but failed to: Control symptoms of OSA; or improve sleep; or reduce AHI/RDI to acceptable levels.
If the patient switches to a bi-level device within the 3-month trial, the length of the trial is not changed as long as there are at least 30 days remaining. If less than 30 days remain of the trial period, re-evaluation must occur before the 120th day (following the same criteria as CPAP adherence).
Read more about Medicare coverage for PAP and supplies here.
Sources:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3119924/
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Frequently asked questions
BiPAP is typically prescribed when: a patient cannot tolerate CPAP at the pressure needed to treat their apnea, when pressure requirements exceed roughly 15 cm H2O, or when they have central sleep apnea, complex sleep apnea, COPD overlap, obesity hypoventilation, or neuromuscular weakness affecting breathing.
For most plans, yes -- there must be documented evidence that CPAP at adequate pressure was tried and was either intolerable or did not adequately treat the apnea. The exception is when the initial titration directly identifies a clinical indication for BiPAP (very high pressure needs, central apnea, hypoventilation).
BiPAP devices are typically 2-3 times the cost of CPAP devices both for purchase price and for monthly insurance reimbursement. Patient out-of-pocket cost depends on deductible, copay, and supplier. Insurance coverage is more restrictive than for CPAP because of the higher cost.
BiPAP delivers two pressures -- higher on inhalation, lower on exhalation -- at a fixed setting. ASV (Adaptive Servo-Ventilation) is a specialized BiPAP variant that adjusts pressure breath-by-breath in real time, specifically for central or complex sleep apnea. ASV is contraindicated in patients with symptomatic heart failure and EF below 45 percent (FDA 2015 safety communication).
Yes, with stricter criteria than CPAP. Medicare requires either documented CPAP failure with a trial of adequate pressure, or initial sleep study findings showing pressure requirements above 15 cm H2O, central apnea, or hypoventilation. The 90-day adherence rule (4 hr / 70 percent of nights) also applies.
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