Round one: CMS says no to in-home sleep tests

Monday, January 31, 2005

WASHINGTON - Medicare won’t be paying for multi-channel home sleep tests anytime soon, according to a draft decision memorandum released in January, but the debate over the test is unlikely to fizzle out in the sleep community.

CMS ruled against covering the test for the diagnosis of sleep apnea after nearly a year of review on the subject. Current national coverage guidelines only cover polysomnography (PSG) tests done in a sleep study laboratory, but some physicians in the field have been promoting the at-home method as a way to ease the overflow at sleep labs and get more people diagnosed.

“The decision was disappointing in that there were some serious errors in CMS’s approach,” said Dr. Terence Davidson, a sleep physician who runs a lab at the University of San Diego’s School of Medicine. “I can deal with no, but not when the decision is made with bad thinking.”

Davidson, who prompted the coverage review with a letter he wrote to CMS in April 2004, said he believes CMS is underestimating the prevalence of sleep disorder breathing among the Medicare population. He said while CMS quotes a prevalence of 2-4%, in reality 10% of seniors and 80% of people with heart failure suffer from OSA.

Davidson argued in his letter to CMS that the current testing inhibits the diagnosis of OSA because the nation’s 692 sleep labs are simply too full to accommodate the numbers of people looking for treatment.

Jerry Barrett, executive director of the American Academy of Sleep Medicine (AASM), which was also involved in the decision process, disagrees. Barrett said AASM surveys completed in 2000-2001 and 2004 do not indicate any access problems.

“The evidence is just simply not there. There is no evidence that waiting lists at sleep labs for testing is prohibitive,” said Barrett. “The people who say there is an access problem just say there is a problem but don’t give any data to support their statement. We did, and we presented preliminary data from the 2004 survey at CMS’s [Medicare coverage Advisory Committee] meeting.”

The MCAC meeting was held Sept. 28 and gathered experts in the field to present evidence either for or against the use of multi-channel testing. The MCAC ruled that they were “moderately confident” that mutli-channel home sleet testing would improve patients health outcomes.

Davidson believes, however, that a poor approach by the MCAC and CMS ultimately prevented a favorable coverage ruling. He believes that biased reports from the AASM and other groups that make their money on PSGs were given too much consideration by the committee.

“Those who are a part of the AASM make a rather lucrative living on in-lab polysomnography testing,” he said. “They own the whole goose that is laying the golden eggs, and they obviously are guarding it jealously.”

Barrett counters that a similar bias exists among those campaigning for coverage for muti-channel sleep tests.

“A lot of people who are proponents of this thing are clearly industry people who have a lot to gain - people who manufacture the tests or are paid members of their boards,” said Barrett. “I don’t think some of those involved made full disclosure of their connections to the industry that stood to gain or loose by whatever decision came out of this thing.”