In response to the Comprehensive Error Rate Testing (CERT) program, Medicare Durable Medical Equipment (DME) contractors CIGNA and NHIC have provided details on their prepayment review of claims for Continuous Positive Airway Pressure Devices (E0601).

The CIGNA review consisted of 100 randomly selected claims paid between Oct. 1, 2009, and Dec. 31, 2009, by 96 different suppliers. DME suppliers were asked to submit medical records to support the coverage criteria. A review revealed that for some claims:

  • The claim contained no medical records submitted.
  • The file did not include a face-to-face clinical evaluation conducted by the treating physician prior to the sleep test that assessed the patient for obstructive sleep apnea (OSA).
  • The physician’s signature on the clinical evaluation did not meet Centers for Medicare & Medicaid Services (CMS) signature requirements.
  • Sleep test was not provided.
The NHIC review involved prepayment complex medical review of 100 claims submitted by 72 suppliers. Sixty-one claims were allowed and 39 were denied, resulting in a claim denial rate of 39 percent. Reasons for denial included:
  • Service determined to be medically unnecessary (36%)
  • Duplicate submission (6%)
  • Rental period exceeded (3%)
  • Requested medical documentation not received (1%)