INTENT

The Income Support (IS) program provides coverage for Continuous Positive Airway Pressure (CPAP) devices for the treatment of moderate to severe Obstructive Sleep Apnea (OSA) when it is medically essential. The IS program does not provide funding for CPAP devices to treat mild OSA.

The IS program does not provide funding to rent a CPAP device.

POLICY

The IS program may provide:

• Up to $1,920.00 for a fixed pressure CPAP device, or
• Up to $2,258.00 for an auto-pressure CPAP device.

The above prices include a CPAP device with a three year warranty, heated humidifier, hose, mask with headgear, chin strap (if needed), and 12 filters.

Replacement CPAP devices may be considered if the warranty has expired and the client confirms that their CPAP device is no longer working.  The IS program does not cover the cost of CPAP device rentals or repairs.

• Edmonton
  Sleep Disorders Lab
  Edmonton General Continuing Care Clinic
  11111 Jasper Avenue, NW
  Edmonton, AB T5K 0L4
  780-342-8310
  
• Calgary
  Foothills Medical Centre Sleep Centre
  1403 29 Street, NW
  Calgary, AB T2N 2T9
  403-944-2404
  
• Lethbridge
  Lethbridge Sleep Clinic
  542 7 Street, S
  Lethbridge, AB T1J 2H1
  403-388-6034

First CPAP Device

Clients requesting a CPAP device for the first time must have a confirmed diagnosis of moderate or severe OSA, complete a CPAP trial, and obtain a prescription for a CPAP device.  This is a two-step process where clients must demonstrate their diagnosis before proceeding to a CPAP trial.

First CPAP Device – Step 1 Substantiation

The IS Worker must not request substantiation documents from Step 2 until the Respiratory/Sleep Medicine Consultant confirms that it is safe to do so.  To proceed without the medical consultant’s advice could put the client’s life in jeopardy.

For their first CPAP device, the client must provide:

• Pulmonary Function Test (PFT) is needed to check for severe lung disease and must include the client’s Body Mass Index (BMI).
  • The PFT must have been completed within the past two years.
  • The BMI from a Level 3 Sleep Study is not a substitute for a PFT.
• Current medication list obtained from the pharmacy (no more than six months old), and
• Full Level 1 or Level 3 Sleep Study including the interpretation by a specialist sleep physician and all graphs, charts, and summaries that make up the study.  Sleep studies older than two years will not be accepted.
  • A Level 3 Sleep Study is not appropriate for everyone.  Clients with the following health concerns will require a Level 1 Sleep Study for their first CPAP device:
    • A BMI above 38,
    • A history or cardiac issues, or
    • Taking narcotic, psychoactive or other medications that affect sleep.
  • In addition, a Level 1 Sleep Study will be required when the Respiratory/Sleep Medicine consultant determines that a Level 3 Sleep Study is insufficient or that CPAP treatment may be unsafe.

First CPAP Device – Step 2 Substantiation

After reviewing the documents from Step 1, the medical consultant will ask the IS Worker to proceed to Step 2.  Substantiation documents from Step 2 must not be requested until the medical consultant confirms that it is safe to proceed.  To do so could put the client’s life at risk.

For their first CPAP device, the client must provide:

• The results of a recent sleep study (1 or 2)
  1. CPAP trial and a Level 3 Sleep Study, including the interpretation by a specialist sleep physician, conducted while the client is being treated with a CPAP device.
     • The CPAP trial must be at least 14 days long.
     • The Level 3 Sleep Study is conducted on the last day of the trial while the client is being treated with a CPAP device. At a minimum, this test must show oxygen saturations and heart rate while the client is being treated with a CPAP device.
     • Tests older than 12 months will not be accepted.
  2. CPAP trial completed in a sleep lab as part of a Level 1 Sleep Study.
     • This test can be arranged by a physician, public sleep clinic or by a private vendor.
     • Tests older than 12 months will not be accepted.
• A doctor’s prescription for a fixed pressure or auto-pressure CPAP device.  The prescription must clearly indicate “fixed” or “auto-pressure” CPAP device, and
• A vendor quote detailing the total cost of the CPAP device specified in the prescription.
  • The quote must include a CPAP device with a three year warranty, heated humidifier, hose, mask with headgear, chin strap (if needed), and 12 filters.

Replacement CPAP Device

In most cases, requests for replacement CPAP devices are completed in one step.  As the client was previously diagnosed and successfully treated with a CPAP device, there are few safety concerns associated with unsupervised CPAP device use.

For replacement CPAP devices, the client must provide:

• The results of a recent sleep study (1 or 2):
  1. A CPAP trial and a Level 3 Sleep Study, including the interpretation by a specialist sleep physician, conducted while the client is being treated with a CPAP device.
     • The CPAP trial must be at least seven days long.
     • The Level 3 Sleep Study must be conducted while the client is being treated with a CPAP device and be completed on the last day of the trial. At a minimum, this test must show oxygen saturations and heart rate while the client is being treated with a CPAP device.
     • Tests older than 12 months will not be accepted.
  2. CPAP trial completed in a sleep lab as part of a Level 1 Sleep Study.
     • These tests can be arranged by a physician, public sleep clinic or private CPAP vendor.
• Pulmonary Function Test (PFT) is needed to check for severe lung disease and must include the client’s Body Mass Index (BMI).
  • The PFT must have been completed within the past two years.
  • The BMI from a Level 3 Sleep Study is not a substitute for a PFT.
• Current medication list obtained from the pharmacy (no more than six months old),
• A doctor’s prescription for a fixed pressure or auto-pressure CPAP device.  The prescription must clearly indicate “fixed” or “auto-pressure” CPAP device, and
• A vendor quote detailing the total cost of the CPAP device specified in the prescription.
  • The quote must include a CPAP device with a three year warranty, heated humidifier, hose, mask with headgear, chin strap (if needed), and 12 filters.
• Clients who did not receive their first CPAP device from the Income Support or AISH program, must also provide a copy of their original Level 1 or Level 3 Sleep Study including the interpretation by a specialist sleep physician and all graphs, charts, and summaries that made up the study.
  • This test would have been conducted just before the client received their first CPAP device.
  • If this information is not available, then a letter from the client’s physician indicating a diagnosis of OSA and successful treatment with CPAP.

When necessary, the Respiratory/Sleep Medicine Consultant will ask for additional information or testing to confirm the client’s continued medical need for a CPAP device and to ensure that CPAP therapy continues to be safe and effective.

PROCEDURE

First CPAP Device

1. The IS worker submits all required documents from Step 1 to CSS.CPAP@gov.ab.ca. The following chart is copied into and completed in the body of the email:
   
   

   DO/Unit/Caseload				Program:  IS
   File Number
   Client Name
   Worker Name
   Worker Phone #
   New CPAP		Other Health Insurance Plan? (yes or no):
   Place an X beside all that apply
   Level 3 Sleep Study (Home Sleep study) – Diagnosis portion			Level 3 Sleep Study (Home Sleep study) – CPAP Trial portion
   Level 1 Polysomnogram (PSG) / Overnight in sleep laboratory			Pulmonary Function Test (PFT) including BMI
   Medication List			Doctor’s Prescription for CPAP
   Vendor Quote			Other:

   
   
2. The medical consultant reviews the documents from Step 1 and provides an expert medical opinion on the safety and effectiveness of CPAP.  Based on the documents provided, the medical consultant will:
   1. Recommend the IS Worker request documents from Step 2,
   2. Request additional or missing information, 
   3. Advise that CPAP is unsafe, or
   4. Advise that CPAP is safe and all documents have been provided.  This may happen when the client has a Level 1 Sleep Study and submits Step 1 and Step 2 documents at the same time.
3. Based on the medical consultant’s recommendation, the IS Worker makes a decision or requests more information from the client or vendor.
4. If the medical consultant advises the IS Worker to proceed to Step 2 or requests additional information, the IS Worker:
   1. Contacts the client or vendor to request the information,
   2. Once received, the IS Worker sends the requested information to CSS.CPAP@gov.ab.ca.  The email must include the client’s name, file number, and IS Worker’s contact information.
5. After all Step 1 and Step 2 documents have been reviewed, the medical consultants will provide a recommendation to approve or deny the request.  The IS Worker reviews the recommendation and makes a decision.
   1. If the decision is to deny the request, the IS Worker must contact the client to explain the reason for the denial.  Clients with additional questions should be directed back to their physician.
   2. If the decision is to approve the request, the IS Worker must notify the client and vendor of the approval.
      1. The IS Worker informs the client and vendor that the approved amount includes a fixed or auto-press CPAP device with a three year warranty, heated humidifier, hose, mask with headgear, chin strap (if needed), and 12 filters.
      2. The IS Worker issues payment for a CPAP device directly to the client or with an EMP 0018 Purchase Authorization and Invoice form.
      3. The IS Worker issues the benefit using LISA need code 1912 Medical/Surgical Supplies.

Replacement CPAP Device

1. The IS worker submits all required documents to CSS.CPAP@gov.ab.ca.  The following chart is copied into and completed in the body of the email:
   
   

   DO/Unit/Caseload					Program:  IS
   File #
   Client Name
   Worker Name
   Worker Phone #
   Replacement CPAP		Other Health Insurance Plan? (Yes or No)
   Previous CPAP provided by IS or AISH programs? (Yes or No)
   ·       If No, original Level 1 or Level 3 sleep study or doctor’s letter attached
   Place an X beside all that apply
   Level 3 Sleep Study (Home Sleep study) – Diagnosis portion				Level 3 Sleep Study (Home Sleep study) – CPAP Trial portion
   Level 1 Polysomnogram (PSG) / Overnight in sleep laboratory				Pulmonary Function Test (PFT) including BMI
   Medication List				Doctor’s Prescription for CPAP
   Vendor Quote				Other:

   
   
2. The medical consultant reviews the documents and provides an expert medical opinion on the safety and effectiveness of CPAP.  Based on the documents provided, the medical consultant will:
   1. Request additional or missing information,
   2. Advise that CPAP is unsafe, or
   3. Advise that CPAP is safe and no further information is required.  
3. Based on the medical consultant’s recommendation, the IS Worker makes a decision or requests more information from the client or vendor.
   1. If additional information is requested, the IS Worker forwards the information once received to CSS.CPAP@gov.ab.ca.  The email must include the client’s name, file number, and IS Worker’s contact information.
4. After all necessary documents have been reviewed, the medical consultants will provide a recommendation to approve or deny the request.  The IS Worker reviews the recommendation and makes a decision.
   1. If the decision is to deny the request, the IS Worker must contact the client to explain the reason for the denial.  Clients with additional questions should be directed back to their physician.
   2. If the decision is to approve the request, the IS Worker must notify the client and vendor of the approval.
      1. The IS Worker informs the client and vendor that the approved amount includes a fixed or auto-press CPAP device with a three year warranty, heated humidifier, hose, mask with headgear, chin strap (if needed), and 12 filters.
      2. The IS Worker issues payment for a CPAP device directly to the client or with an EMP 0018 Purchase Authorization and Invoice form.
      3. The IS Worker issues the benefit using LISA need code 1912 Medical/Surgical Supplies.