What are the requirements for documenting Continuous Positive Airway Pressure (CPAP) compliance for Medicare in adult patients with obstructive sleep apnea?

Medicare CPAP Compliance Documentation Requirements

For Medicare to continue coverage beyond the initial 3-month period, you must document CPAP use of at least 4 hours per night on 70% of nights during any consecutive 30-day period within the first 3 months, combined with a face-to-face clinical reevaluation between days 31-91 showing symptom improvement. 1

Specific Documentation Requirements

Objective Adherence Data

• Usage threshold: CPAP use ≥4 hours per night on ≥70% of nights during a consecutive 30-day period occurring anytime during the first 3 months of therapy 1
• Data source: Objective evidence from CPAP tracking systems (downloaded device data, not patient self-report) 1
• Timing window: This 30-day compliance period can occur at any point between day 1 and day 90 of therapy 1

Clinical Reevaluation Requirements

• Face-to-face visit: Must be conducted by the treating physician (not remote/telehealth under original CMS guidelines) 1
• Timing: No sooner than day 31 but no later than day 91 after initiating CPAP therapy 1
• Documentation of clinical benefit: Written documentation that OSA symptoms have improved with CPAP therapy 1

Initial Coverage Period

• Medicare provides initial CPAP reimbursement limited to 12 weeks (approximately 3 months) 1
• Continued coverage beyond this period requires meeting the above criteria 1

Important Clinical Context

Evidence Limitations of the 4-Hour Rule

The American Thoracic Society notes that insufficient evidence supports the 4-hour/70% threshold as necessary for improved neurocognitive and cardiovascular outcomes 1. Research demonstrates:

• A dose-response relationship exists between CPAP use and clinical outcomes 1
• Even 2 hours of nightly use shows improvement in some outcomes (Epworth Sleepiness Scale, Functional Outcomes of Sleep Questionnaire, Multiple Sleep Latency Test) 1
• Randomized controlled trials show improvements in daytime sleepiness, functional outcomes, cognitive function, and blood pressure with CPAP use <4 hours/night, 70% of nights 1

Common Documentation Pitfalls

• Relying on patient self-report: Patients typically overestimate their CPAP use; always obtain objective device data 2
• Missing the timing window: The face-to-face visit must occur between days 31-91; documentation outside this window may not satisfy Medicare requirements 1
• Inadequate symptom documentation: Simply noting "patient doing well" is insufficient; specifically document which OSA symptoms (daytime sleepiness, nocturia, morning headaches, etc.) have improved 2
• Delayed follow-up: Waiting until day 90 allows problems to become entrenched; early intervention (within 7-30 days) improves long-term adherence 2, 3

Practical Implementation Strategy

Data Collection

Review CPAP tracking system reports showing: 1

• Total nights CPAP was used
• Percentage of nights with usage >4 hours
• Average usage on nights when CPAP was used
• Residual apnea-hypopnea index
• Mask leak data

Clinical Assessment Documentation

Document the following at the face-to-face visit: 2

• Changes in daytime sleepiness (ideally using Epworth Sleepiness Scale)
• Improvement in presenting symptoms (nocturia, headaches, sleep fragmentation)
• Quality of life improvements
• Mask fit issues, skin irritation, or comfort problems
• Any barriers to adherence

For Non-Compliant Patients

If patients fail to meet the 4-hour/70% threshold but show clinical benefit with lower usage, document the clinical improvement thoroughly, though Medicare may still deny continued coverage 4. The American Thoracic Society considers patients adherent if they use CPAP >2 hours/night with demonstrated improvement in daytime sleepiness, quality of life, or other health complications 3, but this does not satisfy CMS requirements 1.