Positive Airway Pressure (PAP) Devices for Obstructive Sleep Apnea - Revised Policy - Important Information for the Ordering Physician
Editor's Note: The following article was written by Dr. Adrian M. Oleck, the Medical Director for DME MAC Jurisdiction B at National Government Services, Inc. WPS Medicare is publishing this article to clarify what DME MACs require to approve CPAP machines. Please note, WPS Medicare does not determine the need for CPAP machines; the DME MACs make this determination based upon the sleep studies. If you have any questions regarding this article or the associated LCD, please contact the DME MAC.
On March 13, 2008, CMS released a revised National Coverage Determination (NCD) for Continuous Positive Airway Pressure (CPAP) devices. The major change was allowing the results of specified home sleep tests to be used to qualify beneficiaries for coverage of CPAP devices. The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have released revised Local Coverage Determinations (LCDs) which incorporate the provisions of the NCD but also include additional coverage criteria. The policies also apply to bi-level positive airway pressure devices (respiratory assist devices, RADs) when they are use to treat obstructive sleep apnea (OSA). CPAP and bi-level devices have been combined into a single LCD - Positive Airway Pressure (PAP) Devices for Obstructive Sleep Apnea.
Note: If a study is not appropriate for the DME MAC to use for its determination of medical necessity, then there is no medical necessity for the original sleep study.
The major requirements for coverage of a PAP device for OSA that pertain to the ordering physician are:
- 1) There must be a face-to-face visit with the physician prior to ordering the sleep test. This should generally include the following elements:
- a) Sleep history and symptoms which may be caused by OSA
- b) Epworth Sleepiness Scale (a standardized patient questionnaire which helps to assess the likelihood of sleep apnea) or other validated sleep inventory
- c) Pertinent physical examination - e.g., body mass index, neck circumference, upper airway exam, and cardiopulmonary exam
- 2) If a home sleep study is performed, it must be one that directly measures airflow and at least two other pertinent physiological parameters (e.g., respiratory movement/effort, oxygen saturation, ECG/heart rate, etc.) and therefore allows determination of apneas and hypopneas used to calculate an apnea-hypopnea index (AHI) or respiratory disturbance index (RDI).
- 3) If a home sleep study is performed, it must be interpreted by a physician who holds either:
- a) Current certification in Sleep Medicine by the American Board of Sleep Medicine (ABSM); or
- b) Current subspecialty certification in Sleep Medicine by a member board of the American Board of Medical Specialties (ABMS); or
- c) Completed residency or fellowship training by a program approved by an ABMS member board and has completed all the requirements for subspecialty certification in sleep medicine except the examination itself and only until the time of reporting of the first examination for which the physician is eligible; or
- d) Active staff membership of a sleep center or laboratory accredited by the American Academy of Sleep Medicine or the Joint Commission.
- Note: Physicians interpreting polysomnograms will be required to meet this requirement for coverage of PAP devices provided after January 1, 2010.
- 4) The sleep study results are:
- a) AHI or RDI is greater than or equal to 15 events per hour, with a minimum of 30 events; or
- b) AHI or RDI is 5-14 events per hour (minimum of 10 events) with documentation of excessive daytime sleepiness, impaired cognition, mood disorders, insomnia, hypertension, ischemic heart disease, or history of stroke.
- (Note: For purposes of this policy, the RDI includes only apneas and hypopneas.)
- 5) To continue coverage for the positive airway pressure (PAP) device (CPAP or RAD) beyond an initial 3 month trial period, there must be:
- a) A face-to-face visit with the physician during the second or third month of the trial that documents an improvement of the beneficiary's symptoms; and
- b) A data report from the PAP device which documents use the PAP device for at least 4 hours per night on 70% of nights for a 30 consecutive day period during the trial.
Additional coverage and payment rules for sleep tests may be found in the local coverage determinations (LCDs) for the applicable Medicare Part A or Part B contractor. There may be differences between those LCDs and the DME MAC LCD. For the purposes of coverage of PAP therapy, the DME MAC coverage criteria take precedence.
The complete medical policy may be viewed on the DME MACs' individual Websites or in the CMS Medicare Coverage Database. The Epworth Sleepiness Scale may be found in the Appendices section of the LCD. Note that the formal title of the policy is Positive Airway Pressure ((PAP) Devices for the Treatment of Obstructive Sleep Apnea. The Web address of the Medicare Coverage Database is http://www.cms.hhs.gov/mcd/search.asp 
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Physicians are reminded that in order for these items to be reimbursed for your patients, the DME supplier will need to collect medical documentation including copies of your initial evaluation, the report of the sleep study, your re-evaluation during the PAP trial, and the data report from the PAP device indicating patient compliance during the trial. Please cooperate with them so that they can provide the device that you have ordered for your patient.
Adrian M. Oleck, M.D.
Medical Director, DME MAC Jurisdiction B
National Government Services, Inc.
8115 Knue Road
Indianapolis, IN 46250
Page Last Updated: Thursday, 18-Mar-2010 05:54:33 CDT
