Wake Up Call for Sleep

The government is taking a closer look at Medicare coverage and payments for sleep therapy devices, which may be the next big reimbursement issue.

The American Association for Homecare has added sleep issues to its list of legislative priorities for the coming year. That list already includes competitive bidding, maintenance and service payments after the 36-month cap for oxygen therapy, the first-month purchase option for power wheelchairs and respiratory medications such as Xopenex.

Recent studies have associated cardiovascular disease with obstructive sleep apnea. More than 12 million people are affected by the disorder, and many receive treatment each year with a CPAP machine, which CMS acknowledges is safe and effective. Yet, the agency continues to provide conflicting policies on payment and testing related to these machines.

For years, debates have raged within CMS and the DME Medicare Administrative Contractors over the coverage of home sleep testing and whether it can be used to diagnose or treat OSA. Recently, multiple local coverage determinations and proposed rules have been released on home sleep testing and coverage, but these home care policies are troubling.

AAHomecare is convening a workgroup of sleep policy experts to respond and is voicing concerns to stakeholders in the sleep community and to the DME MAC medical directors.

Two issues require attention. The first is the DME MAC local coverage determinations for positive airway pressure (PAP) devices for the treatment of OSA. All four DME MACs have released similar LCDs on this issue.

The “initial coverage” and the “continued coverage” criteria are the two main points of contention. The initial coverage requires a face-to-face clinical evaluation with some additional sleep test documentation. The continued coverage criteria include another clinical evaluation after three months of therapy.

There is a high rate of noncompliance with this treatment; however, requiring the beneficiary to return for an evaluation in the fourth month can be a burden for many patients. There is also an ongoing payment liability on the patient and HME provider tied to the face-to-face re-evaluation that requires compliance records showing clinical adherence of 30 consecutive days of using the machine for four or more hours per night.