Doctors rally behind in-home test

Saturday, July 31, 2004

BALTIMORE - Proponents of a proposal that would open Medicare’s door to in-home diagnostics for obstructive sleep apnea outweighed opponents by a significant margin in the first round of comments submitted to CMS.
Overall, 45 of the 81 comments clearly urged CMS to modify its current policy, which requires beneficiaries receiving CPAP to be diagnosed in a lab using polysomnography (PSG); 28 of the comments clearly opposed the proposal.

Among submissions by individual or groups of doctors, the green light for in-home diagnostics was even bolder. While seven submissions from doctors opposed change to the existing policy, 24 of the submissions called for CMS to allow in-home diagnostics. One of those advocating a shift into the home was Dr. William Dement, who is widely known as the ‘father of sleep medicine.’

“A large and growing body of evidence demonstrates excellent correlation between multi-channel home sleep testing and PSG,” Dement wrote.

CMS’s reassessment of its in-home diagnostic policy was prompted by a Jan. 29 letter from Dr. Terry Davidson, a University of San Diego School of Medicine sleep doctor who believes the existing policy is inhibiting the diagnosis of OSA.

In response to the first round of comments, CMS is calling for a second round that focuses on similarities between unattended, portable multi-channel home sleep testing and facility-based PSG.

In an interesting presumptive twist, CMS has asked specifically for the parameters of sleep and cardiorespiratory function that would be required in the home to achieve parity with PSG. As well, CMS wants to know what conditions (i.e. patient education, technician support) would be required to perform effective studies in the home.

If CMS is forecasting the possibility of a modification, the Medicare program would be moving in the direction proposed by one of the several most weighty submissions during the comment period.

In a May 4 letter to CMS, the 12 physicians of Stanford University’s Sleep Disorder’s Clinic wrote that a “modification to Medicare policy for sleep testing coverage determination to include multi-channel home monitoring would be appropriate, if its use were restricted to patients presenting with unambiguous OSA, and if home studies were followed immediately by PSG when the home study findings were negative or equivocal for OSA.”

In opposition, the American Academy of Sleep Medicine argued that there is still “insufficient evidence to support the use of portable home monitoring as it is currently applied in clinical practice … this increase in incorrect diagnosis would be expected to substantially increase unnecessary prescription.”

To many, however, the millions of undiagnosed people with OSA pose a far greater threat than unnecessary prescriptions. Moreover, the mis-prescription of CPAP is not widely considered to be a health threat.

“It has less complications than taking an aspirin,” said one physician at a leading physician-based trade association. “If people aren’t sleeping, let them try a CPAP unit. If it works, it’s better than sending them out for a diagnosis. There’s very little danger as far as we know.”