Is your patient eligible for a CPAP device upgrade?

The replacement of an item past the five-year lifetime will be considered in cases of irreparable wear if the item has been in continuous use by the patient, on either a rental or purchase basis, for the equipment’s useful lifetime.

• Irreparable wear:
  • Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot be identified.
  • In cases involving irreparable wear, the Reasonable Useful Lifetime (RUL) of the equipment is taken into consideration, and in no case can it be less than five years old.
  • Computation of the useful lifetime is based on when the equipment is delivered to the patient, not the age of the equipment.
  • A physician’s written order is needed to reaffirm the medical necessity of the item.
• If a PAP machine is replaced following the five-year RUL, there must be a face-to-face evaluation by the treating physician documenting that the patient continues to use and benefit from the PAP machine. There is no requirement for a new sleep test or trial period. Note: If a DME item reaches its five-year life expectancy, is in good working order and meets the patient’s medical needs, it should not automatically be replaced.

The replacement of an item before its five-year life-time expires can only be done if the item is lost, is irreparably damaged, or the patient’s medical condition changes and the item no longer satisfies the medical needs of the patient.

• Loss or irreparable damage:
  • Irreparable damage is considered damage caused by a specific accident or natural disaster.
  • A physician’s order is needed to reaffirm the medical necessity of the item.

• If a PAP machine is replaced during the RUL because of loss, theft or irreparable damage due to a specific incident, there is no requirement for a new clinical evaluation, sleep test or trial period.
• The supplier must replace the equipment free of charge if it does not last the full five-year period (ie, is no longer serviceable or needs substantial repairs). If it is determined that the item is unable to last for the entire five-year RUL based upon accumulated repair costs (those repair costs exceeding 60% of the cost to replace), the supplier must replace the equipment with properly working equipment at no charge.

Replacement equipment does not need to be new