Reimbursement Criteria

The delivery of appropriate treatment for any condition may at times become problematic if coverage criteria are not met or are not well-documented for the individual patient. This is especially true in the world of SDB for Medicare patients with respect to PAP therapy. There are separate criteria specifically for BPAP or in Center for Medicare and Medicaid (CMS) vernacular, respiratory assist devices. The coverage criteria are divided into four categories but two of these related to patients with either neuromuscular or chronic obstructive lung disease are not pertinent for this chapter. The specifics can be obtained from any regional durable medical equipment regional carrier (DMERC) web site (40). The new regulations released in March 2006 and retroactive to January 1, 2006 recognize two basic pathways for BPAP treatment

FIGURE S A two-minute epoch during Stage 2 sleep with frequent episodes of obstructive apnea and oxygen desaturation. Incidental periodic limb movements are also noted in leg electromyogram channel. Abbreviations: ABD, abdominal plethysmogram; C4-A1, right central-left reference EEG; CZ-OZ, midline central-occipital EEG; ECG, electrocardiogram; EEG, electroencephalogram; EMG, electro-myogram; FZ-CZ, midline frontal-central EEG; HR, heart rate; LOC and ROC, left and right outer canthi (eye movements), respectively; Nasal P, nasal pressure via transducer; RC, rib cage plethysmogram; Sono, sonogram (snoring intensity); SpO2, oxygen saturation; Sum, plethysmogram summed signal.

coverage. The simplest avenue to BPAP is for OSA patients who have a "facility-based" diagnostic PSG and meet criteria for CPAP treatment; yet, CPAP "has been tried and proven ineffective." Although this is nonspecific, it can be utilized if the patient has tried CPAP and is intolerant, nonadherent to CPAP, or it does not satisfy the therapeutic goals. A BPAP device without a backup rate (E0470) can be prescribed and covered under these circumstances. The patients with CompSA can obtain BPAP with a backup rate (E0471 and ASV is considered an equivalent device) through the same pathway as the patients with CSA. This approach also requires a diagnostic PSG and failure with CPAP titration with a primary diagnosis of CSA or CompSA which the DMERC web sites specifically define as:

"Complex sleep apnea (CompSA) is a form of central apnea specifically identified by the persistence or emergence of central apneas or hypopneas upon exposure to CPAP (E0601) or an E0470 device once obstructive events have disappeared. These patients have predominately obstructive or mixed apneas during the diagnostic sleep study occurring at greater than or equal to five times per hour. With use of a CPAP or E0470, they show a pattern of apneas and hypopneas that meets the definition of CSA described earlier."

Central apnea is precisely defined as:

1. An AHI greater than five,

2. Central apneas/hypopneas greater than 50% of the total apneas/hypopneas,

3. Central apneas or hypopneas greater than or equal to 5 times per hour, and

4. Symptoms of either excessive sleepiness or disrupted sleep.

Sergei Eisenstein Montage

FIGURE 4 Another two-minute epoch during non-rapid eye movement stage 2 sleep now with 1O cm H2O of continuous positive airway pressure applied. Note the exaggerated periodic breathing with central apnea pattern now predominating. Abbreviations: ABD, abdominal plethysmogram; C4-A1, right central-left reference EEG; CZ-OZ, midline central-occipital EEG; ECG, electrocardiogram; EEG, electroencephalogram; EMG, electromyogram; FZ-CZ, midline frontal-central EEG; HR, heart rate; LOC and ROC, left and right outer canthi (eye movements), respectively; Nasal P, nasal pressure via transducer; RC, rib cage plethysmogram; Sono, sonogram (snoring intensity); SpO2, oxygen saturation; Sum, plethysmogram summed signal; VEST, estimated flow from device.

FIGURE 4 Another two-minute epoch during non-rapid eye movement stage 2 sleep now with 1O cm H2O of continuous positive airway pressure applied. Note the exaggerated periodic breathing with central apnea pattern now predominating. Abbreviations: ABD, abdominal plethysmogram; C4-A1, right central-left reference EEG; CZ-OZ, midline central-occipital EEG; ECG, electrocardiogram; EEG, electroencephalogram; EMG, electromyogram; FZ-CZ, midline frontal-central EEG; HR, heart rate; LOC and ROC, left and right outer canthi (eye movements), respectively; Nasal P, nasal pressure via transducer; RC, rib cage plethysmogram; Sono, sonogram (snoring intensity); SpO2, oxygen saturation; Sum, plethysmogram summed signal; VEST, estimated flow from device.

The last complicating feature regarding reimbursement is that patients must be followed up and proven adherent with the PAP treatment at least four hours per night between 61 and 90 days after initiation. The whole process demands that formal documentation be readily available for patients and although exact follow-up guidelines are not otherwise provided in any literature, some formal and regular follow-up is generally accepted as good clinical practice (23).

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