DME Carriers Publish Revised LCD for CPAP Coverage

Last week the four DME carriers, CIGNA, NGS, NHIC and Noridian, published their revised local coverage determination (LCD) policy for CPAP. According to the revised draft, the policy allows for CPAP compliance to be documented, "through direct download or visual inspection of usage data with documentation provided in a written report format.” Additionally, the requirements for educating patients about Home Sleep Tests (HST) have been eased, and the policy now allows either face-to-face instruction or video and/or telephone instruction with 24-hour phone support. Physicians interpreting facility-based sleep tests have until January 1, 2010, to meet the credentialing requirements.

Also, the policy states that to be covered, the HST must be one of the following: Type II device that records a minimum of seven channels, EEG, EOG, EMG, ECG/heart rate, airflow, respiratory movement/effort, and oxygen saturation; a Type III device that records a minimum of four channels, ECG/heart rate, airflow, respiratory movement/effort, and oxygen saturation; or a Type IV device that records a minimum of three channels that allow direct calculation of apnea-hypopnea index (AHI) and respiratory disturbance index (RDI).

Further, the policy notes: Devices that record channels that do not allow direct calculation of an AHI or RDI may be considered as acceptable alternatives if there is substantive clinical evidence in the published peer-reviewed medical literature that demonstrates that the results accurately and reliably correspond to an AHI or RDI. This determination will be made on a device by device basis. Currently there is no device that indirectly measures AHI or RDI that meets this criterion.

The updated LCD does maintain the following restrictions on HST:

  1. All sleep tests must be performed by an entity that "qualifies as a Medicare provider of sleep tests” and must be interpreted by a physician who holds either:
    1. Current certification in Sleep Medicine by the American Board of Sleep Medicine (ABSM); or,
    2. Current subspecialty certification in Sleep Medicine by a member board of the American Board of Medical Specialties (ABMS); or,
    3. Completed residency or fellowship training by an ABMS member board and has completed all the requirements for subspecialty certification in sleep medicine except the examination itself and only until the time of reporting of the first examination for which the physician is eligible; or,
    4. Active staff membership of a sleep center or laboratory accredited by the American Academy of Sleep Medicine (AASM) or The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations – JCAHO).
  2. No aspect of an HST, including but not limited to delivery and/or pick-up of the device, may be performed by a DME supplier
  3. To continue to receive payment for CPAP after three months, the patient must be clinically reevaluated and evidence of symptom improvement and CPAP adherence must be documented.

The DME carriers have created a fact sheet with answers to frequently-asked-questions to aid physicians and medical staff.  Click here to download the fact sheet.

2017-10-04T13:57:40+00:00 September 26th, 2008|Professional Development|