The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have released revised Local Coverage Determination (LCD) for positive airway pressure (PAP) devices for the treatment of obstructive sleep apnea (OSA). The revised LCD incorporates the provisions of CMS’s March 13 National Coverage Determination, while expanding to include additional coverage criteria.
Major requirements for coverage of a PAP device include a mandatory face-to-face visit with the physician prior to ordering the sleep test.
The new LCD requires a sleep study, which can be either a facility-based polysomnogram or a Type II, III, or IV home -leep study. The revision now allows home sleep studies conducted through a Type-IV device, acceptable only when the device directly or indirectly allows calculation of an apnea-hypopnea index (AHI) or respiratory disturbance index (RDI). The Watch-PAT devices manufactured by Itamar Medical are currently the only acceptable Type IV devices that indirectly allow calculation of an AHI/RDI (effective for tests conducted on or after January 1, 2009).
Additional requirements for coverage for a PAP device include the following:
• A physician who meets specific criteria must interpret home sleep studies.
• Results of the sleep study must meet certain criteria.
• Continuing coverage for a PAP device beyond the 3-month trial period requires an additional face-to-face visit with a physician and a data report from the PAP device documenting a required level of use.
Additional information on the LCD revision can be found on the CMS Web site.