Medicare Coverage Policy

Medicare Coverage Policy ~ Decisions

Continuous Positive Airway Pressure (CPAP) Therapy Used in the Treatment of Obstructive Sleep Apnea (OSA) (#CAG-00093R)

Official Tracking Sheet Information:

60-17. CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) (Effective for Claims Adjudicated on and After January 12, 1987.)

CPAP is a non-invasive technique for providing low levels of air pressure from a flow generator, via a nose mask, through the nares. The purpose is to prevent the collapse of the oropharyngeal walls and the obstruction of airflow during sleep, which occurs in obstructive sleep apnea (OSA). The diagnosis of OSA requires documentation of at least 30 episodes of apnea, each lasting a minimum of 10 seconds, during 6-7 hours of recorded sleep. The use of CPAP is covered under Medicare when used in adult patients with moderate or severe OSA for whom surgery is a likely alternative to CPAP.

Initial claims must be supported by medical documentation (separate documentation where electronic billing is used), such as a prescription written by the patient's attending physician, that specifies:

o a diagnosis of moderate or severe obstructive sleep apnea, and
o surgery is a likely alternative.

The claim must also certify that the documentation supporting a diagnosis of OSA (described above) is available.

Cross Refer: §60-9.

Medicare Coverage Policy ~ Decisions

Continuous Positive Airway Pressure (CPAP) Therapy Used in the Treatment of Obstructive Sleep Apnea (OSA) (#CAG-00093R)

Tracking Sheet

Issue	The Centers for Medicare & Medicaid Services (CMS), formerly the Health Care Financing Administration, is reviewing the use of CPAP for the treatment of OSA to determine if the national coverage guidelines should be revised. CPAP is a non-invasive technique for providing low levels of air pressure from a flow generator, via a nose mask. The purpose is to prevent the collapse of the oropharyngeal walls and the obstruction of airflow during sleep, which occurs in OSA. The current diagnostic criteria for OSA require the documentation of at least 30 episodes of apnea, each lasting a minimum of 10 seconds, during 6-7 hours of recorded sleep. The use of CPAP is covered under Medicare when used in adult patients with moderate or severe OSA for whom surgery is a likely alternative to CPAP.
Background	CMS received inquiries from manufacturers, clinicians, professional associations and groups, expressing concerns and requesting changes in the national coverage policy for CPAP in the treatment of OSA. Some requestors believe the national coverage policy criteria for establishing the diagnosis of OSA are inconsistent with current diagnostic techniques and standards. There are also discussions concerning the definition and significance of partial cessation of breathing (hypopneas); specifically, that the medical necessity criteria may be too narrow (e.g., surgery is not the option it once was; hypopnea is more widely used and accepted as a diagnostic criteria). CMS has been asked to revise the national coverage policy for CPAP to include Bi-level Positive Airway Pressure (BiPAP), as well as the diagnostic criteria for OSA to include consideration for hypopneas in the diagnosis of patients with moderate or severe obstructive sleep apnea. CMS is in the process of exploring and/or reviewing clinical trials or other medical literature that will assist in determining future revisions to the current national coverage policy for CPAP.
Benefit Category	§1861(n) Durable Medical Equipment
Requestor Name	Durable Medical Equipment Regional Carriers (DMERCs)
Formal Request Completed	June 4, 2001
Current Due Date	October 31, 2001
Lead Analyst(s)	Francina C. Spencer (410) 786-4614
Medical Officer	Joseph Chin, MD (410) 786-4371
Actions Taken
September 14, 2001	On September 4, additional commentary and information was received from the requestor and other sources. In order to consider this new material, the due date is extended to October 15, 2001.
October 10, 2001	Correction: The new information received on September 4 was provided by the manufacturer of a CPAP device and a professional society, not the DMERC. We expect the decision memorandum to be posted by October 31, 2001.
October 30, 2001	Decision Memorandum posted.

CPAP Therapy Used in the Treatment of OSA

As of October 1, 2002 at 11:27:08 AM EDT (-0500), the U.S. population was
288,181,442. With estimates that about five percent of the population suffers from

obstructive sleep apnea, that means there are potentially

14,409,072 apneics in the U.S.

As of October 1, 2002 at 11:27:08 AM EDT (-0500), the world population was
6,253,616,576. With estimates that about five percent of the population suffers
from obstructive sleep apnea, that means there are potentially

312,680,829 apneics in the world.

Awake In Philly is a support group for individuals who have been diagnosed with at least one of the recognized sleep disorders, as well as anyone else impacted by those with sleep disorders. The information on the Awake In Philly website is not intended to replace medical advice, nor is any information to be misinterpreted as an attempt to diagnose, treat, cure, or prevent any disease.

If you have questions about any of the medical conditions mentioned on this website, especially if you suspect that you (or someone you know) has sleep apnea, please contact a qualified medical professional immediately. The information is intended to provide support, guidance, and encouragement to others contending with the many challenges of sleep disorders. The goals of Awake In Philly are to support, educate, and inform those who feel the impact of sleep disorders, as well as the general public. Medical advice should only come from qualified, licensed, and trained health-care professionals.

This site was last revised: Thursday, 17 October 2002 12:13 PM

Page URL: