By: Andrea Stark
Managing Member, MiraVista, LLC

In March, Medicare's CPAP policy underwent a significant, but easily overlooked, change in the basic coverage criteria that could render some of your CPAP patients as non-qualifying. The change was prompted by a CMS directive that required the CPAP policy to reflect the existing Medicare National Coverage Determination Manual, Chapter 1, Section 240.4 and affects which occurrences of apneas and hypopneas can be utilized to qualify a patient for CPAP equipment. The wording of the medical policy now reads:

"The apnea-hypopnea index (AHI) is defined as the average number of episodes of apnea and hypopnea per hour and must be based on a minimum of 2 hours of sleep without the use of a positive airway pressure device, reported by polysomnography using actual recorded hours of sleep" (i.e., the AHI may not be extrapolated or projected).

Prior to the update the policy reflected a more liberal interpretation and mirrored standard operating protocol in many sleep labs. The previous policy allowed for the AHI to be established based on two hours of recording time. More frequently sleep labs are using baseline, split night, and titration studies which can make this more stringent, 2-hour requirement difficult to obtain. Suppliers must take action to ensure sleep centers are sufficiently educated on these changes. Many sleep centers have changed operating protocol to obtain results based on recording time instead of recorded sleep.

The effective date of the policy change was retroactive to January 1, 2006. However because the policy was not published until March, suppliers cannot be held liable until the publication date. Medicare is expecting claims submitted after March will be compliant under the revised policy guidelines. Unfortunately, the PSCs and DMERCs have made no mention of grandfathering CPAP patients that were qualified under the previous instruction.

Many feel that another "sleeper" provision in the CPAP policy requiring "surgery as likely alternative" is too restrictive as it is not a likely alternative for many patients that would benefit from CPAP therapy. In order to make any changes to the policy, interested parties must follow the official instructions for changing National Coverage Determinations: http://www.cms.hhs.gov/DeterminationProcess/Downloads/FR09262003.pdf.

The good news is that the DMERC/PSC medical directors recognize the benefit these devices bring to patients and they are on board with many of today's industry standards. This is evidenced in the Respiratory Assist Device policy which is not governed by a national coverage determination. The looser interpretation on the AHI criteria still appears in the RAD policy, and a few changes were recently made to the Central Sleep Apnea diagnosis group based on requests from national associations. Industry standards certainly support a change, and if enough momentum is felt on this subject we could effect a change.