4309 W 96th Street
Indianapolis, IN 46268
Office 317-872-9702 or 800-848-4670
Fax 317-872-9704
CPAP set up requirements
__Face to face w/ in 30 days of today
__Polysomnogram and titration results (titration optional)
__Look for AHI or RDI
__If AHI or RDI is between 5 and 14, there must be a supporting dx included in the face
to face or sleep study interpretation notes of excessive daytime sleepiness, mood
disorder, impaired cognition, insomnia, hypertension, heart disease, or hx of stroke.
__If AHI or RDI is 15 or above you are good!
__Rx for CPAP and supplies w/ pressure, diagnosis, Physician’s printed name, Physician’s
signature, and length of need.
Public S Server/ DME Intake forms 4/4/13
4309 W 96th Street
Indianapolis, IN 46268
Office 317-872-9702 or 800-848-4670
Fax 317-872-9704
Bipap set up requirements (Neuromuscular Disease, ALS)
__Face to face w/ in 30 days of today
__Documentation of neuromuscular disease must be in the patient’s medical record (for
example, amyotrophic lateral sclerosis).
__The neuromuscular patient should have ONE of the following pulmonary function test
showing
__Maximal inspiratory pressure is <60 cm H20
__Forced vital capacity is <50% predicted.
__ Titration study recommended to ensure optimal Bipap settings, but not required.
__Rx for BiPap and supplies w/ settings, diagnosis, Physician’s printed name, Physician’s
signature, and length of need
Public S Server/ DME Intake forms 4/4/13
4309 W 96th Street
Indianapolis, IN 46268
Office 317-872-9702 or 800-848-4670
Fax 317-872-9704
Bipap set up requirements (Severe COPD)
__Face to face w/ in 30 days of today
__Face to face notes and/or CPAP titration report MUST state that patient FAILED CPAP trial in
order to qualify. If we don’t have that documentation, we do not set the BiPap up.
__ALL of these following criteria need to be met.
__Pt. should have an ABG (arterial blood gas) w/ in 30 days of today showing the PaC02
greater than 52.
__Pt. needs to have an overnight oximitry w/ in 30 days of today, on at least 2L of 02,
using their current CPAP showing 02 sat 88% or below for 5 minutes or more. (This
proves the need of BiPap vs. CPAP)(This can be performed in a sleep lab or the home)
__Documentation stating that the MD has reviewed the overnight oximitry stating that
the patient has failed CPAP due to the increased amount of C02 in the blood, and
increased 02 needs at night.
__ Polysomnogram AND titration results (titration must be included for Bipap) (No date
requirement)
__Look for AHI or RDI
__If AHI or RDI is between 5 and 14, there must be a supporting dx of excessive daytime
sleepiness, mood disorder, impaired cognition, insomnia, hypertension, heart disease,
or hx of stroke.
__If AHI or RDI is 15 or above you are good!
__Rx for BiPap and supplies w/ pressure, diagnosis, Physician’s printed name, Physician’s
signature, and length of need
Public S Server/ DME Intake forms 4/4/13
4309 W 96th Street
Indianapolis, IN 46268
Office 317-872-9702 or 800-848-4670
Fax 317-872-9704
Bipap set up requirements (Restrictive lung disease, Non-ALS)
__Face to face w/ in 30 days of today
__Documentation of neuromuscular disease or a severe thoracic cage abnormality must
be in the patient’s medical record. This documentation should show a dx of severe
thoracic cage abnormalities, central sleep apnea (CSA), complex sleep apnea (Comp SA),
or hypoventilation syndrome.
__Patient should have ONE of these tests done to qualify.
__Pt. should have an ABG (arterial blood gas) performed on patient’s prescribed 02 level
while awake w/ in 30 days of today showing the PaC02 greater than or equal to 45.
__Pt. needs to have an overnight oximitry w/ in 30 days of today, on at least 2L of 02,
using their current CPAP showing 02 sat 88% or below for 5 minutes or more. (This
proves the need of BiPap vs. CPAP)(This can be performed in a sleep lab or the home)
__Documentation stating that the MD has reviewed the overnight oximitry or ABG stating that
the patient is in need of a BiPap instead of a CPAP due to the increased amount of C02 in the
blood, and/or increased 02 needs at night.
__ Polysomnogram and titration study recommended to ensure optimal settings, but not
required.
__Rx for BiPap and supplies w/ settings, diagnosis, Physician’s printed name, Physician’s
signature, and length of need
Public S Server/ DME Intake forms 4/4/13