Expanded CPAP guidelines effective April 1

Thursday, January 31, 2002

WASHINGTON - CMS has made its acquiescence to expanded CPAP coverage official by announcing an April 1 start date for the new policy. Sleep providers are both pleased and optimistic that it will bring a groundswell of new business.

The revised National Coverage Decision guidelines, under consideration by CMS since last fall, will adhere to the clinically accepted Apnea Hypopnea Index, a sleep pattern benchmark that is less restrictive than Medicare's current standard. While Medicare's current eligibility threshold is 30 apnea episodes during six to seven hours of sleep, the more relaxed AHI allows for a combination of 10-second apneas and shorter hypopneas during a two-hour sleep period.

By adopting the looser policy - already embraced by many private payers - sleep therapy providers say not only will more patients qualify for Medicare coverage, but that monitoring sessions can be cut in half, allowing a higher volume of patients to be tested in a shorter amount of time.

It all adds up to greater business potential, providers say.

"This will have a significant effect and give us a pop on the Medicare side of our business," said John Goodman, president and CEO of Houston-based Health Management Services.

Harry Lawrence, clinical coordinator and co-owner of Advanced Oxymed Services in Fishkill, N.Y., says the development will primarily benefit his lab business. While he doesn't expect a heavy influx of new patients, the AHI standard will provide extended coverage for borderline patients.

"Counting hypopneas won't make a significant difference in the number of patients we see, but it will for titration study reimbursement," said Lawrence, who owns and operates four independent sleep labs. "It will be people who are coming in anyway who now qualify for coverage they wouldn't have gotten before." HME