Does A7036 require prior authorization?

Yes, A7036 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for A7036?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`A7036`, Chinstrap used with positive airway pressure device

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

A Standard Written Order (SWO) must be communicated to the supplier before claim submission, and a signed Written Order Prior to Delivery (WOPD) must be received before delivery of DMEPOS base items; the SWO/WOPD must list the base item and may list separately billed options/accessories.

Sleep test documentation must demonstrate compliance with NCD 240.4.1 and applicable A/B MAC LCD/Billing & Coding articles, show FDA approval of the diagnostic device, be ordered by the treating practitioner, and be conducted by a Medicare-qualified and state-compliant provider.

To justify billing an E0470 for OSA, documentation must show an E0601 was tried and proven ineffective during facility titration or home use despite optimal therapy (proper mask fitting and appropriate pressure settings).

For continued coverage beyond the first 3 months, the treating practitioner must document an in-person re-evaluation (between day 31 and 91 after initiation) showing symptom improvement and must review objective adherence data from the device.

Beneficiaries who fail the initial 12-week trial require an in-person re-evaluation to determine reasons for failure and a repeat facility-based Type I sleep test (diagnostic, titration or split-night) to re-qualify for PAP.

Suppliers must document contact with the beneficiary and an affirmative refill request prior to dispensing recurring DMEPOS supplies and maintain such documentation in their files.

Key Coverage Criteria

A single-level CPAP device (E0601) is covered for obstructive sleep apnea (OSA) when the beneficiary has an in-person clinical evaluation by the treating practitioner prior to the sleep test.
An E0601 is covered when a valid sleep test shows AHI or RDI >= 15 events/hour with a minimum total of 30 events.
An E0601 is covered when a valid sleep test shows AHI or RDI between 5 and 14 events/hour with a minimum total of 10 events and there is documented excessive daytime sleepiness, impaired cognition, mood disorder, insomnia, or cardiovascular comorbidity (hypertension, ischemic heart disease, or history of stroke).
The beneficiary and/or caregiver must receive instruction from the supplier in proper use and care of the PAP equipment before coverage of the device.
The diagnosis of OSA for PAP coverage must be based on a Medicare-valid sleep test (Type I/II/III/IV/Other) that is FDA-approved as a diagnostic device, ordered by the treating practitioner, and conducted by a Medicare-qualifying sleep test provider in compliance with state regulations.
A bi-level respiratory assist device without back-up rate (E0470) is covered for OSA when criteria A–C for E0601 are met and a therapeutic trial of E0601 has been tried and proven ineffective.

9 Active Policies

EVICORE-HPLAN-CIGNA_MEDICARE-268F28B96146, Cigna Medicare Advantage Durable Medical Equipment Code List - Effective 01/01/2025

L33718, Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea

L33800, Respiratory Assist Devices

BCBSIL-MED204.006, Medical Management of Sleep Related Breathing Disorders

BCBSMT-MED204.006, Medical Management of Sleep Related Breathing Disorders

BCBSNM-MED204.006, Medical Management of Sleep Related Breathing Disorders

BCBSOK-MED204.006, Medical Management of Sleep Related Breathing Disorders

CARELON-sleep-disorder-management-2024-10-20-updated-2025-07-01-for-anthem-bcbs-ohio-medicaid-and-regence-only-deferred-to-2025-12-01, Sleep Disorder Management

CARELON-sleep-disorder-management-2025-11-15-updated-2026-07-01, Sleep Disorder Management

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A7036, Chinstrap used with positive airway pressure device