Positive Airway Pressure (PAP) Devices Quarterly Results of Targeted Probe and Educate Review

The Jurisdiction D, DME MAC, Medical Review Department is conducting a Targeted Probe and Educate (TPE) review of HCPCS code(s) E0601 as well as any additional codes on the claim for the related policy. The quarterly edit effectiveness results from October 2025 - December 2025 are as follows:

Based on dollars, the overall claim potential improper payment rate is 18%.

Top Medical Necessity Denial Reasons

  • The medical record documentation does not contain a sleep test. Refer to National Coverage Determination 240.4 & Local Coverage Determination L33718.
  • There is no documentation to support the provider of the PAP device conducted education on the proper use and care of the device. Refer to National Coverage Determination 240.4 & Local Coverage Determination L33718.
  • The medical record documentation does not contain a clinical evaluation by the treating practitioner prior to the sleep test. Refer to National Coverage Determination 240.4 & Local Coverage Determination L33718.

Top Technical Denial Reasons

  • Documentation was not received in response to the Additional Documentation Request (ADR) letter.
  • Related item denied due to invalid Standard Written Order (SWO).
  • Related item denied due to overutilization.

Educational Resources

Suppliers billing Medicare should be familiar with the documentation requirements and utilization parameters. Visit the Positive Airway Pressure Devices webpage to access coverage documents (Local Coverage Determination (LCD), Policy Article, National Coverage Determination (NCD)); documentation letters, forms, and checklists; reviews; tips; tools; resources; related articles; and educational events and tutorials, if applicable.

See the CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3 information about probe/error validation reviews.

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