CPAP Face to Face Reevaluation: What Medicare Requires

Updated October 2026. Written by Matteo Grassi, clinical psychologist and cofounder of HANA Health.

The CPAP face to face reevaluation is the in person visit Medicare requires between day 31 and day 91 of therapy. At that visit the treating practitioner documents that sleep apnea symptoms improved and reviews device data showing at least 4 hours of use on 70% of nights in a 30 day window. Without it, Medicare's 2024 revision of the PAP coverage policy denies continued coverage after month three.

Clinically, this visit is the moment a patient hears whether the mask is actually working for them. For the DME, it's also the moment continued rental and supply billing gets approved or lost.

Key facts

• Continued coverage of a PAP device (E0470 or E0601) requires a clinical reevaluation no sooner than day 31 and no later than day 91 after therapy starts (Medicare LCD L33718, revision effective January 2024).
• The visit must document that OSA symptoms are improved and that the practitioner reviewed objective adherence data (LCD L33718).
• Adherence means PAP use of 4 hours or more per night on 70% of nights during a consecutive 30 day period within the first three months (LCD L33718).
• Formal assessment of improvement can't be documented before day 31, and usage data must be a written report from a download or visual inspection, kept in the medical record (Policy Article A52467).
• A late visit isn't fatal: coverage restarts on the date of a later reevaluation that meets the criteria (LCD L33718).
• Insufficient documentation caused 71.2% of improper payments for PAP devices in the 2024 reporting period, and CMS put the CPAP improper payment rate at 12.5% (CMS Medicare Learning Network).
• In a randomized trial of 556 patients prescribed CPAP, Medicare adherence was 53.5% with usual care and 73.2% with telemonitoring plus education (Hwang et al., AJRCCM, 2018).

What is the CPAP face to face reevaluation?

It's the second clinical visit in Medicare's PAP pathway, and it's the one that decides whether coverage continues past the initial three months. The first visit, before the sleep test, establishes the diagnosis. The reevaluation shows the therapy is working and the patient is using it.

Medicare treats the first three months as a trial. During the trial, rental and supplies are covered once the diagnosis criteria are met. After it, the supplier can only keep billing with the KX modifier on the fourth month's claim and every month after if both the initial and continued coverage criteria are met, according to Policy Article A52467.

The pillar guide on Medicare CPAP compliance requirements covers the full pathway. This article stays on one step: the visit.

When does the visit have to happen?

Between day 31 and day 91 after therapy starts. The LCD says the practitioner must act "no sooner than the 31st day but no later than the 91st day." One caution: a 2024 letter to physicians from the DME MAC medical directors words the end of the window as the 90th day, so treat day 90 as your working deadline.

The adherence window and the visit window are different things. The 30 day adherence period can fall anywhere in the first three months, so a patient can hit the standard early. The visit still can't count until day 31.

Here's a worked example of the arithmetic:

• The threshold: 70% of 30 nights is 21 nights with at least 4 hours of use.
• Patient A: 22 qualifying nights in one 30 night stretch is 73%. That meets the standard.
• Patient B: 20 qualifying nights is 67%. That misses the standard in that stretch, so check every possible 30 day stretch in the first three months before calling it a miss.
• Visit on day 28: perfect data, but too early. The visit doesn't count.
• Visit on day 45: inside the window. Valid.
• Visit on day 95: late. Coverage commences on the visit date, so the days in between aren't covered.

What must the visit note document?

Two things, both in the record: improved OSA symptoms and objective adherence data that the practitioner reviewed. A requirements checklist, based on the LCD and the policy article:

1. An in person visit by the treating practitioner, dated on or after day 31 and within the window.
2. Improvement in symptoms, stated specifically (sleepiness, snoring, morning headaches, whatever the patient reports), not "doing well."
3. Objective adherence data from a direct download or visual inspection of usage, in a written report.
4. Evidence the practitioner reviewed that report, with the report kept in the medical record.
5. The usage meeting the standard: 4 hours or more on 70% of nights across a consecutive 30 day period.

Supplier forms don't substitute. The policy article states that a supplier generated form, even if the practitioner fills it out, isn't a substitute for the comprehensive medical record. The data doesn't have to go in with the claim, but it must be available on request.

CMS's electronic review reason codes show how denials get written. Reviewers cite no in person reevaluation between day 31 and day 91, a reevaluation before day 31, no evidence the patient benefits, no objective adherence evidence, and no proof the practitioner reviewed that evidence (CMS esMD reason codes).

Can the reevaluation be done by telehealth?

The LCD text says in person. The October 2024 DME MAC physician letter describes the visit as "in person or Medicare approved telehealth" (CGS and Noridian DME MAC letter, 2024). Those two sources don't match word for word.

Medicare telehealth rules have changed several times since 2020, so I can't tell you what applies to a given visit date. Confirm with your DME MAC before you count a video visit toward the requirement. If a claim depends on it, get the answer in writing.

What happens if the visit is late or the patient isn't adherent?

If the visit happens after day 91 and the patient meets both criteria, continued coverage starts on the date of that visit. If the criteria aren't met, continued coverage and accessories are denied as not reasonable and necessary.

A failed trial isn't permanent. To requalify, the patient needs an in person reevaluation to determine why therapy failed, plus a repeat facility based Type 1 sleep test, which can be a diagnostic, titration or split night study (LCD L33718).

There's also a fair debate about the rule itself. At the 2026 American Thoracic Society conference, Kaiser Permanente Southern California researchers presented data on 132,492 patients issued CPAP from 2015 to 2023. About 49% would have met the CMS standard in the first 90 days, and 36% of those who wouldn't have were still using CPAP at one year, as reported by Medscape. That's a conference presentation, and it doesn't change the rule. It does show why early numbers don't tell the whole story.

How do you get patients to the visit on time?

Start with the data and work backward. The visit has to follow the adherence window, so a patient who's tracking toward 21 qualifying nights by day 30 should already have an appointment booked for the second half of month two. That's a practical suggestion, not a Medicare rule.

Reaching patients is the hard part. In the Tele OSA randomized trial, 556 patients were prescribed CPAP. Medicare adherence was 53.5% with usual care, 65.6% with automated telemonitoring and feedback messaging, and 73.2% with telemonitoring plus web education. Education alone didn't significantly improve adherence, though it did raise the show rate to the sleep evaluation visit, 68.5% versus 62.7% (Hwang et al., 2018). That trial ran in one health system and measured adherence and attendance at the evaluation, not completion of the day 31 to 91 visit.

Adherence also keeps slipping after the trial. In claims linked to device data for 213,341 commercially insured adults, 48% met the CMS style standard in all four 90 day quarters of the first year (Alpert et al., CHEST, 2024).

What this means for your DME

Treat the reevaluation as an operational deadline with an owner, not a clinical afterthought. Three steps help most:

1. Track each patient's setup date and compute day 31 and day 90 on day one.
2. Pull the usage report as soon as the patient clears 21 qualifying nights, and send it to the practitioner with the visit request.
3. Chase the visit note, not just the data. A good download with no signed note still fails an audit.

If your team does RTM around CPAP monitoring, read the CY2027 RPM and RTM contractor proposal explainer before you plan staffing. HANA Health builds voice follow up for the first 90 days of CPAP therapy and documents each call to the chart. You can read about it on the HANA Sleep page.

Frequently asked questions

Can the DME supplier do the reevaluation instead of the doctor?

No. The reevaluation belongs to the treating practitioner. Suppliers can send the usage report and a request, but a supplier generated form isn't a substitute for the practitioner's own medical record.

What if the patient hits 4 hours on 70% of nights by day 25?

The adherence standard can be met early, because the window only has to fall inside the first three months. The visit still can't be documented as a formal improvement assessment before day 31, so the clock for the visit starts later than the clock for the data.

Does the usage report have to go in with the claim?

It doesn't have to be submitted with the claim. It does have to be in the medical record and available if Medicare asks, as a written report the practitioner reviewed.

What if the patient moves from CPAP to a bilevel device during the trial?

It depends on how many days remain. If more than 30 days remain in the trial, the reevaluation still falls between day 31 and day 91 of the original device. If fewer than 30 days remain, the reevaluation and adherence documentation must come before the 120th day (LCD L33718).

Does a failed trial mean the patient can never get CPAP covered?

No. The patient can requalify with an in person reevaluation of why therapy failed and a repeat facility based sleep test.

Sources

1. Centers for Medicare & Medicaid Services, Local Coverage Determination L33718, Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea, revision effective 2024.
2. Centers for Medicare & Medicaid Services, Policy Article A52467, PAP Devices for the Treatment of Obstructive Sleep Apnea.
3. Centers for Medicare & Medicaid Services, Medicare Learning Network, Continuous Positive Airway Pressure Devices and Accessories, 2024 reporting period.
4. Centers for Medicare & Medicaid Services, esMD CPAP Reason Codes and Statements.
5. DME MAC Medical Directors (CGS and Noridian), Dear Physician: PAP Devices, Initial Qualification, revised October 2024.
6. Hwang D, et al., Effect of Telemedicine Education and Telemonitoring on CPAP Adherence: The Tele OSA Randomized Trial, American Journal of Respiratory and Critical Care Medicine, 2018.
7. Alpert N, et al., Performance of Claims Based Algorithms for Adherence to PAP Therapy in Commercially Insured Patients With OSA, CHEST, 2024.
8. McNamara D, CMS CPAP Rule Could Deny Coverage for Some Who Benefit Long Term, Medscape, June 11, 2026, reporting an ATS 2026 conference presentation.

This article is educational and isn't billing, coding, clinical or legal advice. Check current CMS guidance and your MAC before you bill. If you want to talk through your CPAP adherence workflow, book a discovery call.