Sleep rivals duke it out before CMS

Sunday, October 31, 2004

WASHINGTON - Proponents and opponents of in-home sleep studies for obstructive sleep apnea prepared to face off Sept. 28 before CMS in what could prove to be a winner-take-all victory for one side or the other.

The face-off pitted supporters of in-home studies against those in favor of traditional polysomnography (PSG).

CMS’ Medical Coverage Advisory Committee, described by some as the “Supreme Court of CMS,” convened the public meeting to evaluate whether medical evidence submitted over the course of two comment periods and several presentations would support a decision by Medicare to open its doors to in-home diagnostics. A final decision from CMS is expected this fall.

“MCAC is such a substantial undertaking for CMS, that one would have difficulty imagining that Medicare would make a decision that did not support the MCAC findings,” said Dr. Terence Davidson, head of the sleep lab at the University of San Diego’s School of Medicine.

A letter to CMS from Davidson prompted this discussion in January. In that letter, Davidson argued that CMS’s current policy of recognizing only PSG tests is inhibiting the diagnosis and treatment of OSA.

“There are backlogs of significant length at some sleep labs,” said Davidson. “Once the question of OSA has been raised, it is simply not fair to tell someone they have to wait six to 12 weeks to get tested.”

The 16-member MCAC, chaired by Dr. Ron Davis, of the Center for Health Promotion and Disease Prevention at Henry Ford Hospital, will use data from several presentations by proponents and adversaries in formulating its decision. One such presentation brought together some heavy weights in the world of sleep medicine, including Dr. William Dement, who is widely considered the “father of sleep medicine.”

“We basically tried to show that there are thought leaders and people who have been involved in the very basics of sleep medicine since day one who feel that [in-home testing] is a perfectly acceptable if not desirable way to go,” said Dr. Mike Coppola, medical director of Mercy Hospital’s sleep laboratory in Springfield, Mass.

That panel presented a number of studies supporting Davidson’s initial letter and also talked about private insurance’s acceptance of the technology and the growing prevalence of sleep disordered breathing and the pressure that has placed on sleep labs.

CMS also has solicited two rounds of comments on the issue, with the second focusing on the similarities between unattended portable multi-channel home sleep testing and the facility-based PSG.

“I, at one time, tried to take a look at the data and prove my personal bias that a home sleep test was the better test, but when I looked at the data it doesn’t prove that one or the other are different,” said Davidson. “They are identical. They are so identical that it is ridiculous and anybody that looks at it without a bias could only conclude that.”

Opponents contend that in-home tests do not provide a quality level of care and are not comprehensive enough to diagnose complex cases.

“[In-home tests] do not provide technical support, do not allow meaningful therapy investigation, and will force duplication by requiring a follow-up, attended study,” said a board of sleep specialists at the Minnesota Lung Center and Minnesota Sleep Institute. “The patient will not be served under these circumstances.”