Medicare Announces Final Coverage Policy For Continuous Positive Airway Pressure Therapy For Obstructive Sleep Apnea

Main Category: Sleep / Sleep Disorders / Insomnia
Also Included In: Medicare / Medicaid / SCHIP
Article Date: 14 Mar 2008 - 5:00 PDT

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The Centers for Medicare & Medicaid Services (CMS) expanded Medicare coverage for continuous positive airway pressure (CPAP) devices to include beneficiaries who have been diagnosed, using a home sleep test, with obstructive sleep apnea. CMS also announced changes to simplify certain test requirements.

Obstructive Sleep Apnea (OSA) is a condition in which periods of temporary suspension in breathing (apnea) occur during sleep. In most instances, OSA is diagnosed by counting the number of sleep disturbances that occur during a specific time interval. Up to four million Medicare beneficiaries may suffer from some form of OSA.

The CPAP devices provide air pressure through a face mask to help keep breathing passages open during sleep. Medicare's current policy provides CPAP coverage only for beneficiaries who have OSA diagnosed using a specific type of sleep test called polysomnography in an attended sleep laboratory setting. CMS' new policy will add coverage for CPAP following a positive at-home sleep test.

In the home tests, the patient wears a device during sleep that collects and records data about airflow and other measurements. The patient takes the device to the physician, who uses the data collected by the device to determine whether the patient has obstructive sleep apnea or needs further sleep studies or assessment.

Some patients with OSA do not continue with CPAP treatment or do not improve on treatment. Thus, CMS is limiting initial coverage of CPAP for OSA to twelve weeks to determine if the beneficiary will respond to the CPAP treatment. Long term CPAP is covered for those beneficiaries who continue and respond to treatment.

"Our revised policy provides more options for Medicare beneficiaries and their treating physicians," said CMS Acting Administrator Kerry Weems. "At the same time, we remain vigilant to ensure that Medicare payments for these services do not create incentives for inappropriate use."

CMS will continue to monitor the use of the CPAP home testing services, examining the potential for fraud and abuse as well as making recommendations to implement appropriate safeguards to mitigate potential risk.

The final national coverage determination announced is available on the CMS web site here.

Centers for Medicare & Medicaid Services