Cigna’s Hoover Explains Recent Sleep LCD; ‘Chill,’ Says MED Group’s Riley

ATLANTA–Questions were flying across the industry’s sleep
sector last week after a recent Local Coverage Determination
declared that in-home sleep studies “are not covered.”

The LCD surprised providers, particularly since CMS’ proposed
decision memorandum on coverage for CPAP therapy, issued Dec. 14,
would allow home sleep testing.

But not to worry, according to Robert D. Hoover, Jr., senior
medical director for Cigna Government Services: The LCD was a
Fiscal Intermediary policy update in response to coding changes and
has no bearing on CMS’ National Coverage Determination–expected no
later than March 13–regarding criteria for CPAP coverage.

“The contractors have a mandated schedule for updating our
policies when there are HCPCS changes (within 90 days/120 days).
Policies with the new CPAP HCPCS codes from Jan.1, 2008, got
published without regard to the upcoming NCD. This was a Fiscal
Intermediary policy, not a DME MAC update; however, I suspect their
policy update is due to the same reason we update our
policies–HCPCS code changes,” Hoover explained.

The Jurisdiction C medical director also pointed out there could
be a bit more confusion to come. With transition of medical review
responsibilities from the DME Program Safeguard Contractors to the
DME Medicare Administrative Contractors, official as of March 1,
the current policies must be posted on the MAC Web sites.

“Once we approve, our policies will also display to the public,
and the CPAP policy will be essentially unchanged except for the
changes in the HCPCS codes from Jan. 1, 2008. So like the FI
policy, ours, too, will still have the same language prohibiting
home sleep studies.”

Kelly Riley, director of the National Respiratory Network for
The MED Group, Lubbock, Texas, said attendees at the network’s
annual meeting last week also were stumped by the LCD because it
had been issued ahead of CMS’ anticipated final coverage
policy.

“It’s just that every time we see the words ‘home sleep
testing,’ we jump,” Riley said. “But as strange as this sounds,
this [LCD] doesn’t have a thing to do with CPAP coverage. This LCD
came from a Fiscal Intermediary … and because of some coding
changes, they had to reissue the policy. Every time there is a
change in the codes, they are required to reissue the policy so
everybody is clear.

“What we have to remember,” Riley continued, “is that the NCD is
on its way, so we as an industry need to chill.”

Under current CMS policy, obstructive sleep apnea patients must
be diagnosed through a sleep lab test, or polysomnography, for
Medicare to cover the cost of CPAP therapy. But the agency’s draft
memo recommended changes, which, among others, would allow the use
of home sleep testing.

Hoover said the NCD should be out this month as expected. But he
speculated that, based on previous decisions, its effective date
could be “out to July 1 or maybe even Oct. 1. Once the NCD is final
and has an effective date, the [medical directors] will update the
CPAP policy with a new effective date that coincides with the NCD
effective date and update the coverage language in the policy to
reflect the coverage criteria of the NCD.”

“I just came out of three days of being with top industry
experts on this area,” Riley said of MED’s meeting, which hosted
attendees from more than 70 companies in 32 states, “and we talked
about [this] LCD.

“If I had to put this in a simple blurb,” she concluded, “I
would say ‘Sit tight. This LCD does not affect us, and at this
point there are really no changes.’ This was purely an
administrative function of the Fiscal Intermediary, and we are
still waiting for the NCD.”