Medicare Pap Guidelines - Compliance Requirements
Medicare and most insurance plans require that compliance is met on your behalf. Please see the information listed below regarding compliance requirements.
What is compliance?
Beneficiary to use PAP device minimum of 4 hours or more, 30 days consecutively, within the first 90 days, 70% or greater. We recommend you use the device the whole time your sleeping, not just the minimum.
Follow up with your physician 30 days after your start therapy and discuss therapy outcomes. Your physician must indicate you benefit from PAP therapy, so your insurance can continue payment.
What happens if I am not compliant?
If you are not compliant 70% or greater within the first 90 days you have the following options
- If you like to continue therapy and have your insurance payer consider payment of the device, then you will need to schedule the following:
- Physician appointment explaining what the barriers/ issues were and why you couldn’t use the PAP device as directed
- Schedule an In-Lab sleep study (not home) test
- If you do not want to continue therapy then you can schedule the following:
- Contact XMED to schedule return of PAP device
- Return the PAP device at any local Medical Xpress Retail Location
- If you want to continue therapy, keep the PAP device, and not have another study
- Contact XMED to provide the form to be completed for this option and arrange final payment(s) of device
- Please note, any replacement supplies will not be covered by your insurance payer since compliance was not met and will be an out of pocket expense.
- Are there any exceptions to the compliance rules?
Most insurance payers only allow one exception to compliance requirements. If the beneficiary has been admitted to inpatient status (hospital admission, skilled nursing home, rehab center, etc.). The compliance timeframe will be extended for the time while inpatient status. Medical records/ documentation will be required to prove the inpatient status.
Who do I contact if I have problems with my PAP therapy?
You can call XMED Sleep Success Team at 866-216-9633 Ext 1311 for assistance, or physician’s office.