Pacific Sleep Program

LCD L171 for Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea.pdf

Primary Care referral requirements Summary:

o Patient has a face-to-face clinical evaluation by the treating physician prior to the sleep test to asses for potential OSA.
o Clinical evaluation must include: Sleep history and symptoms including but not limited to:

" Snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches: and,

" Epworth Sleepiness Scale; and,

" Physical Examination that documents body mass index, neck circumference, and a focused cardiopulmonary and upper airway system evaluation.

NOTE: by completing the new referral form and having the patient complete the Epworth Sleepiness Scale you will be completing the necessary information now required by Medicare for OSA referrals

o 61st-91st day follow up

" After initiation of therapy with PAP equipment from a DME provider each patient must return to their treating physician between 61 and 91 days for a face to face evaluation of improved OSA symptoms; and,

" Objective Evidence of adherence to use of PAP equipment

Adherence to therapy is defined as use of PAP > 4 hours per night on 70% of nights during a consecutive 30 day period anytime during the first Three (3) months of initial usage.

NOTE: adherence to use of PAP equipment should be processed by the DME provider and can be download by them if proper PAP equipment is provided. We will be working closely with the DME companies to try and ensure that they understand Medicare's new policy.

URGENT: Medicare Changes in diagnosis and treatment requirements for OSA patients

Effective September 1, 2008 Medicare rules governing the coverage of positive airway pressure therapy in the treatment for Obstructive Sleep Apnea (OSA) patients will significantly become more prohibitive for referring physicians, diagnosing sleep specialists, and durable medical equipment therapy providers. I personally want to assure you that the Pacific Sleep Program's new sleep center in Astoria, which is now open and seeing patients, is fully qualified under these new more significantly stringent Medicare standards.

These new regulations state that Medicare OSA patients will only be eligible for positive airway pressure therapy equipment benefits if the diagnosing sleep study is interpreted by a board certified sleep disorder specialist, as you are aware I am, or by a physician working for an accredited sleep disorder center, which Pacific Sleep Program is.

Additionally there are new referral requirements before a Medicare patient can have sleep testing plus, a follow up appointment is required during a 61-91 day window post treatment initiation if the patient going to continue positive airway pressure therapy. We are updating our referral form with the new information requirements to ensure that, once completed; your requirement for proper Medicare referral of a Medicare OSA patient is assured.

Pacific Sleep Program will be working closely with all our clinical partners and DME providers to try and ensure that no patients who are referred for diagnosis will face the uncertainty of wondering if their treatment for OSA will be covered by Medicare. The following pages briefly outline the language contained in the LCD determination. If you wish to see a complete copy of Noridian's LCD L171, you can do so here.

If you have any feedback or questions about Pacific Sleep Program and these new Medicare regulations, please feel free to call me anytime.

Regards,
Gerald B. Rich
Director, Pacific Sleep Program
Diplomate, American Board of Sleep Medicine