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 July 2025 – September 2025 are as follows:

Based on dollars, the overall claim potential improper payment rate is 11%.

Top Medical Necessity Denial Reasons

  • 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.
  • The medical record documentation does not support the beneficiary continues to use and benefit from the PAP device following the 5-year reasonable useful lifetime (RUL). Refer to National Coverage Determination 240.4 & Local Coverage Determination L33718.
  • The medical record documentation does not indicate the apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events or the AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia; or hypertension, ischemic heart disease, or history of stroke. 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: 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.

Last Updated $dateUtil.getDate( $modifieddate , "MMM dd , yyyy" , $locale , $tzone )