Continuous Positive Airway Pressure Reimbursement In The United States

For any therapeutic plan to be viable for the patient, it must be accessible and reimbursable. The coverage criterion throughout the world varies but, generally, more socialized governmentally directed care is difficult to access, but is more favorably reimbursed. The opposite is true in the United States where accessibility to care is typically easy, but coverage criteria are usually more cumbersome. Throughout the world, a physician must not only decide the appropriate treatment but also ensure that the patient can access the treatment recommended. The Center for Medicare and Medicaid (CMS) in the United States has unique coverage criteria that for appropriate patient management must be understood. The following is pertinent for patients dependent on CMS coverage criteria, but clinicians worldwide are encouraged to familiarize themselves with similar issues in their area.

Patients with suspected OSA are mandated to undergo a diagnostic study in a "facility-based polysomnography laboratory" with a minimum of 120 minutes of recorded sleep. This stipulation was largely inserted to emphasize the CMS bias against empiric or portable sleep study diagnosis of OSA. An apnea-hypopnea index (AHI) of 15 events per hour is required in order to qualify for coverage, unless the patient has symptoms of hypersomnolence or cardiovascular consequences such as hypertension, in which case they need only demonstrate five events per hour.

Access to alternative treatment such as auto-titration CPAP (APAP) or bilevel PAP (BPAP) is surprisingly easy since the criteria are not specified for APAP at all because the reimbursement is equivalent to simple CPAP and the only stipulation necessary to utilize BPAP is for the physician to stipulate that "CPAP has been tried and proven ineffective." The ineffectiveness of the CPAP can be on the basis of intolerance or poor response and the time period of decision-making is not stipulated, so there is much left to the discretion of the treating physician. Under no circumstance can a BPAP device with a backup rate be prescribed for OSA alone and, if desired, this requires an additional diagnosis, such as central sleep apnea, restrictive lung disease with neuromuscular disease or thoracic cage abnormality or, hypercapnic chronic obstructive lung disease failing BPAP without a BPAP rate. The complete coverage criteria for CPAP and BPAP devices are available online1.

Websites for CPAP and BPAP—must cut and paste into website address to work:

http://www.adminastar.com/Providers/DMERC/MedicalPolicy/Files/CPAPSystemsRev42.pdf

http://www.adminastar.com/Providers/DMERC/MedicalPolicy/Files/RespiratoryAssistDevicesRev42.pdf

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