Patient Name Date of Referral:
Referring Physician’s name, registration number and designation (please print):
Physician’s signature
Telephone number:
If a Level 3 Sleep Study was performed, how was the optimal pressure determined to treat the patient’s apnea?
2. What is the age of the current PAP device? (mmmm)/ (yyyy)
3. Please conrm why a replacement is required: (change in condition, machine cannot be repaired, etc.)
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
Request for Coverage for Positive Airway Pressure Machine
Assessment Form
INSTRUCTIONS:
1. Have your physician complete this form.
2. Attach the form and all receipts/estimate to your claim form. Retain copies of all documents for your records.
3. Submit your claim to the Benet Payment Ofce indicated on your claim form.
4. For Residents of Saskatchewan, Manitoba and Ontario: You must apply for coverage through the appropriate Provincial Health Program before
submitting a claim or estimate to Canada Life.
Section 1: Complete for all Positive Airway Pressure System Devices:
1. What type of machine does the patient require? CPAP machine APAP machine BPAP machine
2. What type of request is this? Initial machine Replacement Machine (Please proceed to Section 4)
3. What type of sleep study did the patient participate in?
Level 1 – Clinic/Lab Sleep Study Level 3 – In Home Sleep Study Other:
Please attach a copy of the Sleep Study Diagnostic Report.
4. Which diagnosis does the Sleep Study conrm? (check one):
Mild OSA Moderate OSA Severe OSA
Section 2: Complete if requesting an APAP Device:
1. Does the patient have a documented diagnosis of sleep disorder where there is a change in
pressure of a minimum of 4cm H2O on a prescribed xed CPAP level of 10 cmH2O or more? Yes No
2. Does the change in pressure occur between REM vs. NREM or supine vs. non-supine? Yes No
Section 3: Complete if requesting a BPAP Device:
1. Does the patient have a documented diagnosis of OSA/OSAS and despite CPAP of 15 cmH2O or greater exhibits one of the following?
Nocturnal hypoxemia (O2 saturation < 88%) Nocturnal hypercapnia (end tidal CO2) Apnea/hypopnea index > 10
2. Does CPAP of 15 cmH2O or greater resolve the physiological abnormalities but the patient is
unable to tolerate this pressure? Yes No
3. Is the patient unable to tolerate any level of CPAP or continues to complain of excessive daytime
sleepiness (EPW
ORTH score ≥e 10)?
Yes No
Section 4: Replacement PAP Device:
1. What was the patient’s previous device? CPAP APAP BPAP
Form completed by:
Questions? call toll free1.800.957.9777
www.canadalife.com
M7476(PAP)-1/20
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Any modification of this document without the express written consent of Canada Life is strictly prohibited.
