Medicare announces final CPAP coverage policy for obstructive sleep apnea

The Centers for Medicare & Medicaid Services (CMS) today 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 characterized by the complete cessation of breathing for a period of at least 10 seconds (apnea) during sleep. In most instances, obstructive sleep apnea 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 obstructive sleep apnea.

The CPAP devices provide air pressure through a face mask to help the person maintain a patent airway which ensures the person does not stop breathing during sleep.

Medicare‘s current policy provides CPAP coverage only for beneficiaries who have obstructive sleep apnea 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 at-home tests, the patient will wear a device while sleeping that will collect and record data about airflow and other measurements. The patient will then take the device to their physician. From there, the the data collected by the device will be used to determine whether the patient has obstructive sleep apnea or needs further sleep studies or assessment.

Some patients with obstructive sleep apnea do not continue with CPAP treatment or do not improve on treatment. Thus, CMS is limiting initial coverage of CPAP for obstructive sleep apnea 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," Weems added.

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 today is available on the CMS web site at http://www.cms.hhs.gov/center/coverage.asp.

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