PAP LCD: Comparison of Latest Revisions, Initial Provisions

MURRYSVILLE, Pa.–While the DME MACs’ re-issued PAP local
coverage determination still prohibits HME providers’ involvement
in home sleep testing, the new LCD has been characterized by some
in the industry as a “kinder” version of the sleep policy. (See

HomeCare Monday, Sept. 22.)

Courtesy of Philips Respironics, following is a comparison of
revisions in the new PAP LCD to provisions in the initial LCD,
which was issued, then pulled back, in July.

Revised LCD:
Initial exam – May include sleep history, Epworth and physical exam
but not every exam required to have each
Original LCD:
Initial exam – Sleep history, Epworth and physical exam
REQUIRED

Revised LCD:
Type IV device – Monitors and records a minimum of three
channels that allow direct calculation of an AHI or RDI as defined
in policy
Original LCD:
Type IV device – Monitors and records a minimum of three (3)
channels that must include respiratory effort, airflow and oxygen
saturation

Revised LCD:
WatchPAT not specifically mentioned in policy
Original LCD:
WatchPAT specificially identified in policy

Revised LCD:
As of Nov. 1, 2008, patients must receive HST instruction by the
entity providing the device and not a DME supplier; either
face-to-face or via video or telephone with 24-hour troubleshooting
availability
Original LCD:
HST patient instruction must be provided face-to-face by the
testing entity and not a DME supplier

Revised LCD:
For PAP devices with initial dates of service on or after Nov. 1,
2008, all HSTs must be interpreted by a physician who holds
either:
1. Current certification in Sleep Medicine by the American Board of
Sleep Medicine (ABSM); or,
2. Current subspecialty certification in Sleep Medicine by a member
board of the American Board of Medical Specialties (ABMS);
or,
3. Completed residency or fellowship training by an ABMS member
board and has completed all the requirements for subspecialty
certification in sleep medicine except the examination itself and
only until the time of reporting of the first examination for which
the physician is eligible; or,
4. Active staff membership of a sleep center or laboratory
accredited by the American Academy of Sleep Medicine (AASM) or The
Joint Commission (formerly the Joint Commission on Accreditation of
Healthcare Organizations – JCAHO).
For PAP devices with initial dates of service on or after Jan. 1,
2010, physicians interpreting facility-based polysomnograms (Type
I) must meet one of the requirements listed above (1-4) for
credentialing.
Original LCD:
All sleep tests must be interpreted by:
1. A diplomat of the American Board of Sleep Medicine (ABSM);
or,
2. Diplomat in Sleep Medicine by a member board of the American
Board of Medical Specialties (ABMS); or,
3. An active staff member of a sleep center or laboratory
accredited by the American Academy of Sleep Medicine (AASM) or The
Joint Commission (formerly the Joint Commission on Accreditation of
Healthcare Organizations – JCAHO).

Revised LCD:
DME supplier involvement – SAME as initial PAP LCD
Original LCD:
DME supplier involvement – No aspect of an HST, including but not
limited to delivery and/or pickup of the device, may be performed
by a DME supplier. This prohibition does not extend to the results
of studies conducted by hospitals certified to do such tests.

Revised LCD:
Coverage beyond first three months – For PAP devices with
initial date of service 11/1/08 or after: face-to-face exam between
the 31st and 91st day and objective measure of compliance
Original LCD:
Coverage beyond first three months – face-to-face exam
between the 61st and 90th day and objective measure of
compliance

Revised LCD:
Compliance definition – Same as initial PAP LCD
Original LCD:
Compliance is defined as PAP usage of 4 hours per night for 70% of
the nights in a consecutive 30-day period during the first 90 days
of therapy

Revised LCD:
Documentation of adherence to PAP therapy shall be accomplished
through direct download or visual inspection of usage data with
documentation provided in a written report format to be reviewed by
the treating physician and included in the beneficiary’s
medical record. This information does not have to be submitted with
the claim but must be available upon request.
Original LCD:
Documentation of adherence to PAP therapy shall be accomplished
through direct download. This information does not have to be
submitted with the claim but must be available upon request

Revised LCD:
Beneficiaries who fail the initial 12 week trial are eligible to
requalify for a PAP device but must have both:
1. Face-to-face clinical re-evaluation by the treating physician to
determine the etiology of the failure to respond to PAP therapy;
and,
2. Repeat sleep test in a facility-based setting (Type 1
study)
Original LCD:
Not addressed

Revised LCD:
If the physician re-evaluation does not occur until after the 91st
day but the evaluation demonstrates that the patient is benefiting
from PAP therapy as defined in criteria 1 and 2 above, continued
coverage of the PAP device will commence with the date of that
re-evaluation
Original LCD:
Not addressed

Revised LCD:
If a CPAP device is tried and found ineffective during the initial
3 month home trial, substitution of a RAD (E0470) does not change
the length of the trial unless there is less than 30 days remaining
in the trial period. If more than 30 days remain in the trial
period, the clinical re-evaluation would still occur between the
31st and 91st day following the initiation of CPAP. If less than 30
days remain in the trial period, the clinical re-evaluation must
occur before the 120th day following the initiation of CPAP
Original LCD:
If a CPAP device is tried and found ineffective during the initial
3 month home trial, substitution of a RAD (E0470) does not change
the length of the trial

Revised LCD:
If a CPAP device was used for more that 3 months and the patient
was switched to a RAD, then the clinical re-evaluation would occur
between the 31st and 91st day following the initiation of the RAD.
There would also need to be documentation of adherence to therapy
during the 3 month trial with the RAD
Original LCD:
If a CPAP device was used for more that 3 months and the patient
was switched to a RAD, then the clinical re-evaluation would occur
between the 60th and 91st day following the initiation of the RAD.
There would also need to be documentation of adherence to therapy
during the 3 month trial with the RAD

Revised LCD:
327.23 OSA is the only acceptable qualifying diagnosis code
Original LCD:
327.23 OSA is the only acceptable qualifying diagnosis code

Revised LCD:
If the supplier chooses to hold claims for the fourth and
succeeding month pending receipt of information from the treating
physician but learns that the beneficiary did not receive a
clinical re-evaluation between the 31st and 91st day but rather was
re-evaluated at a later date and had documented improvement in OSA
symptoms and is adhering to PAP therapy, those claims may then be
submitted with the KX modifier but only for dates of service
following the date of the clinical re-evaluation
Original LCD:
Not addressed

For FAQs on the new LCD and a link to the complete PAP policy on
the Jurisdiction C DME MAC (Cigna) Web site,
click here.