Thank you for choosing Oxygen One

Referring to Oxygen One for sleep therapy is as simple as faxing the following to our office:

Patient Demographics

  • Name
  • DOB
  • Phone number
  • Address
  • Insurance information

Five Element Order Prescription including:

  • Patient's name
  • Description of the item
  • Provider signature
  • Provider's NPA
  • Date

**Click here to download a Positive Airway Pressure Prescription**

Chart Notes

Physician signed clinical notes from a face to face visit up to 6-months prior to a sleep study, supporting medical necessity and discussing symptoms. A chart note’s primary purpose is to demonstrate the clinical necessity and show why the patient requires therapy.  

A valid note should include:

  • History
  • Signs and symptoms of sleep-disordered breathing (snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches)
  • Duration of symptoms
  • Validated sleep hygiene inventory such as the Epworth Sleepiness Scale
  • Physical exam
  • Focused cardiopulmonary and upper airway system evaluation
  • Neck circumference
  • Body mass index (BMI)

Qualifying Testing

Board certified or eligible sleep physician interpretation of a sleep study (PSG or home sleep test) with a copy of tracings where either the patient’s apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) is greater than or equal to 15 events per hour with a minimum of 30 events; or the AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events and documentation of excessive daytime sleepiness, impaired cognition, mood disorders, or insomnia.   

Please remember, after 3 months of therapy, we will need documentation of another face-to-face appointment with the patient confirming the diagnosis of OSA, demonstrating the compliant use of PAP therapy and a benefit from using therapy/improvement of symptoms. 

For further information on Medicare’s coverage guidelines, click here for their Local Coverage Determination of Wisconsin

Click on the following links for a qualification flow chart to assist in determining if  your patient qualifies for a CPAP/AutoPAP, BiPAP, or BiPAP-ST.  

If you have questions about the referral process at any time, please contact our office for assistance.