Medicare issues revised sleep policies

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Sunday, September 21, 2008

WASHINGTON - Just weeks after pulling new local coverage determinations (LCDs) for positive airway pressure (PAP) devices, the four DME MACs released revised versions Sept. 18.

The revised policies, for initial dates of service on or after Nov. 1, 2008:

* Clarify the apnea-hypopnea index (AHI) and respiratory disturbance index (RDI) results. Patients qualify for treatment if the AHI or RDI is greater than or equal to 15 events per hour with a minimum of 30 events; or if the AHI or RDI is greater than or equal to 5 and less than or equal to 14 events per hour with a minimum of 10 events. Additional specified documentation required.

* Require beneficiary education by the entity conducting home sleep tests (not the DME provider).

* Require compliance documentation through a face-to-face clinical re-evaluation performed by a physician. Documentation about OSA symptoms improving required.

* Require a face-to-face clinical re-evaluation performed by a physician and repeat sleep test in a facility-based setting if a patient fails the initial 12-week trial period of PAP therapy.

* Excludes providers from being involved in any aspect of a home sleep test, including the delivery and/or pick up of devices.

The MACs will not be accepting public comments on the revised LCDs.

In March, CMS released a national coverage determination for PAP devices, and in July, the four DME MACS released LCDs that went above and beyond. They included a host of new coverage criteria for PAP devices, including a 12-week compliance requirement for patients.

Industry stakeholders like AAHomecare and the American Academy of Sleep Medicine responded with requests to reopen the discussion.

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