Continuous Airway Positive Pressure (CPAP) & PAP Supplies Pre-Pay Review Quarterly Status Report
Below is the analysis of claim denials for CPAP HCPCS codes A7027-A7034, A7044, and E0601 reviewed July 1 – September 30, 2024. The error rate for this quarter is 18.44%. The top 10 reasons for claim denials are as follows:
| Rank | Reason | Percent |
|---|---|---|
| 1. | The order is missing a description of the item. | 18.63% |
| 2. | Documentation does not include a valid sleep study that meets all LCD requirements. | 15.84% |
| 3. | Payment for supplies billed above normal policy usage is being denied due to lack of documentation to support that they are reasonable and necessary. | 12.22% |
| 4. | Documentation does not include a valid in-person evaluation that meets all LCD requirements. | 10.87% |
| 5. | The medical record documentation did not include an in-person evaluation conducted following Medicare eligibility or the evaluation did not confirm a diagnosis of obstructive sleep apnea and continued use of the positive airway pressure device. | 10.14% |
| 6. | The documentation was not timely (within the preceding 12 months) to support continued need by the beneficiary. | 8.07 % |
| 7. | The documentation does not have a valid order. | 7.04% |
| 8. | The claim is billed for greater quantity than the order shows. | 6.11% |
| 9. | There is no documentation to support the provider of the CPAP device conducted education on the proper use and care of the device. | 2.59% |
| 10. | The medical record documentation does not have a clinical evaluation by the treating practitioner prior to the sleep test. | 1.97% |
*The total percentage will be greater than 100% because some claims denied for multiple reasons.
**The error rate included is an overall average for the supplier specific reviews as a part of the Targeted Probe and Educate program. This is not meant to be an overall error rate for the HCPCS code or policy under medical record review.
Resources:
- Positive Airway Pressure (PAP) Devices for the Treatment of OSA Documentation Checklist

- Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea – LCD (L33718)

- Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea – Policy Article (A52467)

- Positive Airway Pressure (PAP) Medical Review Resources
- Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)

- Supplier Manual Chapter 3 – Supplier Documentation

Updated: November 5, 2024

