The Centers for Medicare & Medicaid Services (CMS) has proposed to extend Medicare coverage for continuous positive airway pressure (CPAP) devices to include beneficiaries who have been diagnosed with obstructive sleep apnea (OSA) as a result of a Type II, III, or IV home sleep test (HST).

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 4 million Medicare beneficiaries suffer from OSA.

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 via polysomnography (PSG) in an attended sleep laboratory setting.

"Our proposed policy to extend coverage for continuous positive airway pressure provides more options for Medicare beneficiaries and their treating physicians," says Kerry Weems, CMS acting administrator.

CMS also proposes to expand coverage of CPAP under the Coverage with Evidence Development (CED) process to include beneficiaries who have been diagnosed with OSA based either on a clinical evaluation alone or on a diagnostic test other than a PSG or Type II, III, or IV HST. To be covered under CED participation in a research study is required. Such studies must meet the standards outlined in CMS’ Clinical Trial Policy.

Additionally, CMS is proposing to modify the current requirement for a minimum of 2 hours of continuous recorded sleep during tests, recognizing that some patients with very severe OSA are unable to meet that requirement. The proposed policy considers a test positive if the total number of required sleep disturbances is achieved more than 2 hours, regardless of whether 2 hours of continuous sleep has occurred.

CMS is also proposing that any initial coverage of CPAP for OSA be limited to 12 weeks to determine if the beneficiary will respond to the CPAP treatment.

"The proposed policy encourages and supports additional evidence development to determine other means of diagnosing obstructive sleep apnea," Weems says. "CMS also will continue its ongoing commitment to monitoring the over utilization of continuous positive airway pressure devices."

CMS plans to issue a final national coverage determination in March 2008. CMS invites public comments on its proposed decision.

[www.medicalnewstoday.com, December 20, 2007]