CMS has expanded its coverage for CPAPs to include beneficiaries diagnosed with obstructive sleep apnea via home sleep testing devices types II, III and IV.
However, CMS said in the national coverage determination (NCD) that due to the fact that some OSA patients do not continue with CPAP treatment or do not improve with that treatment, it is limiting CPAP treatment for OSA to 12 weeks to determine if beneficiaries will respond to the treatment. It added that long-term CPAP coverage would be provided for patients who respond to the treatment.
“Our revised policy provides more options for Medicare beneficiaries and their treating physicians,” said CMS Acting Administrator Kerry Weems in a prepared statement. “At the same time, we remain vigilant to ensure that Medicare payments for these services do not create incentives for inappropriate use.”
According to Wachovia Capital Markets, which monitors the home sleep testing and CPAP markets, the NCD left many questions unanswered, including:
How much will pay for CMS pay for home sleep tests? Wachovia noted that CPT code 95806 pays $202 for unattended tests, but it has not yet been determined if this is enough to administer those tests profitably.
Who can administer the tests? Wachovia said that the policy “seems to leave the door open for HMEs to play some role,” but is “just as vague as the proposal.”
How does CMS gauge the CPAP benefit after the initial 12 weeks? Wachovai said it is assumed this would be based on Apnea/Hypopnea Index improvement, but the NCD does not make any clear definition.
How will titration be handled? While auto-setting flow generators would likely be involved, they are not currently reimbursed at a higher rate, Wachovia, noted.
Read the decision summary at www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=204.
