On November 1, 2008, a new Local Coverage Determination (LCD) for Positive Airway Pressure therapy for the treatment of Obstructive Sleep Apnea was implemented by all four DME MACs. The following information highlights the new responsibilities of the ordering/treating physician. These policy changes ONLY apply to traditional Medicare fee-for-service patients covered by Part B. They do not apply to most managed care organizations patients.
In addition to a positive diagnosis of Obstructive Sleep Apnea (327.23) via a Medicare-covered sleep study, 2 face-to-face evaluations are required for initial and continued Medicare coverage for PAP therapy.
Face-to-Face Evaluation 1: There must be a face-to-face evaluation with the treating physician prior to ordering any sleep test. This may include documentation of the following in the patient’s medical record:
- Sleep history and symptoms
- A standardized patient questionnaire which helps to assess the likelihood of sleep apnea
- Pertinent physical examination e.g., body mass index, neck circumference, upper airway exam, and cardiopulmonary exam
Face-to-Face Evaluation 2: Following the set-up of the device, the patient must see the treating physician again, sometime between the 31st and 91st day, to document whether there has been improvement in the patients symptoms.
- The physician must review data from the PAP device. For a patient to qualify for Medicare coverage, the device must document use at least 4 hours per night on 70% of nights for a 30 consecutive day period during the trial.
Medicare coverage of the PAP device beyond the first 3 months is contingent upon demonstration of patient benefit from the use of a PAP device and your documentation of these face-to-face evaluations. Apria Healthcare will provide you with PAP usage information for the Medicare beneficiaries you have entrusted to our care for the treatment of Obstructive Sleep Apnea. We will also provide you with the documentation we require for your review and signature to ensure continued coverage of therapy for your patient.
Medicare Beneficiaries Converting to BiLevel
The Medicare LCD for Positive Airway Pressure Devices for OSA also outlines the following criteria for coverage of BiLevel therapy for patients with a diagnosis of Obstructive Sleep Apnea:
- Patient must meet all initial coverage criteria for CPAP
- CPAP must be tried and proven ineffective based on a therapeutic trial conducted in either a facility or in a home setting. Ineffective is defined as documented failure to meet therapeutic goals using a CPAP during the titration portion of a facility-based study or during a home use despite optimal therapy (i.e., proper mask selection and fitting and appropriate pressure settings).
- Physician must document in the patient’s medical record that both of the following issues were addressed prior to changing to a BiLevel device.
- Interface Fit and Comfort. An appropriate interface has been properly fit and the beneficiary is using it without difficulty. This properly fit interface will be used with the BiLevel device.
- The current pressure settings of the CPAP prevent the beneficiary from tolerating the therapy and lower pressure settings of the CPAP were tried but failed to:
- Adequately control the symptoms of OSA; or
- Improve sleep quality; or
- Reduce the AHI/RDI to acceptable levels
Substitution of a BiLevel within the initial 90-day trial period does not require a new face-to-face evaluation or new sleep study.