Articles
CMS Reviews NCD for CPAP Therapy
On March 14, the Centers for Medicare & Medicaid Services (CMS) announced it was reviewing its national coverage determination regarding the diagnosis of patients with OSA requiring CPAP therapy.
Responding to a formal written request from the American Academy of Otolaryngology-Head and Neck Surgery, CMS will review the coverage for in-home sleep testing, redefining the two-hour sleep rule and putting patients on PAP therapy without a formal polysomnography.
The current NCD states that only polysomnography done in a facility-based sleep study laboratory can be used to identify patients with OSA requiring CPAP. In-home testing was reviewed just two years ago.
“This is very rare that they’re actually opening up the coverage policy again within such a short time frame,” says Christen Pettit, reimbursement/marketing specialist at ResMed, Poway, Calif.
The introduction of low-cost, effective in-home testing and auto-PAP to titrate patients plus a broader acceptance of placing patients on CPAP without a sleep study have fueled the reconsideration, says Ron Richard, senior vice president of Strategic Marketing Initiatives, ResMed.
“In addition to that, there are what I’d call triage management systems being employed by self-insured private payors and even the VA, which looks at stratifying the care and the amount of money spent on patients based on how complex or sick they are,” says Richard. “For instance, with sleep if you have a patient that is falling asleep right in front of you, the doctor pretty much knows they’re sleep deprived, sick — (especially if) they have a BMI index that’s excessive, they have a history of loud snoring and they stop breathing at night. So, they’re doing auto-PAP trials on patients like that or they just simply do an overnight oximetry test. If they’re desaturating, they try them on CPAP or auto-PAP for a couple of weeks, download the data and just see how they’re doing.”
Of course, those who don’t do well undergo an overnight, attended PSG.
“I think it would be a positive thing for patients in particular because it would get them into treatment sooner, and it would be less expensive and would save the health care system some money,” says Richard. “And it would still be appropriate.”
CMS will consider amending the two-hour rule for determining the Apnea-Hypopnea Index (AHI). The proposed change would read: “The AHI is equal to the average number of episodes of apnea and hypopnea per hour and must be based on a minimum of two hours of sleep or less if the actual number of AHI episodes recorded is 30 or more in less than two hours, recorded by polysomnography using actual recorded hours of sleep (i.e., the AHI may not be extrapolated or projected).”
The public comment period ended April 13 and a proposed decision memo is expected Sept. 14, 2007. To review the posted tracking sheet, visit https://www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=204.
